Founded 1897 • New Series

Romanian Journal of

Military
Vol. CXXVII • No. 1/2024 • January

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REVISTA DE MEDICINĂ MILITARĂ

• The Impact of Total Synovectomy on Blood Loss and Knee Function. A Prospective Randomized Study
• Evaluation of Serum Magnesium Levels in Patients with Hypertension: A Case-control Study
• Combat Stress in Military Personnel: Theory, Genesis, Prevention, and Control
• A Survey on Mental Health Status in West of Iran: A Spatial Analysis
• Investigating the Predictive Power of the Theory of Planned Behavior on the Behavioral Intention of Healthy Eating in Adolescents
• A Conceptual Analysis of Post-psychotic Depression
• Evaluation of Adsorption Therapy as an Extracorporeal Blood Purification Technique in Critically Ill Covid-19 Patients
• Psychometric Properties of the Method "Evaluation of Negative Mental Reactions and States of Combatants" and Experience of its Application in
Short-term Psychological Recovery
• Associations Between Medical Students' Opinions on Usage of Internet Services and Digital Teaching Tools
• The Impact of Physical Therapy on Psychomotor Functions in a Patient with Systemic Lupus Erythematosus and Diabetes Mellitus

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Cătălin Cîrstoiu (Traumatology) Lucian Negreanu (Internal Medicine) Valentina Uivăroși (Pharmacology)
Gabriel Constantinescu (Gastroenterology) Claudiu Nistor (Thoracic surgery) Octavian Vasiliu (Psychiatry)
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Romanian Journal of Military Medicine, New Series, vol. CXXVII, No 1/2024, January
ISSN-L1222-5126; eISSN 2501-2312; pISSN 1222-5126
Romanian Journal of

Military
Medicine Founded 1897•New Series
Vol. CXXVII • No. 1/2024, January

Contents
Mihnea A. Petre, Mihai E. Gherghe, Dragoș C. Cotor, Alexandru Luchian, Liliana L. Preotescu, Cristian Scheau,
Romică Cergan
● The Impact of Total Synovectomy on Blood Loss and Knee Function. A Prospective Randomized Study 3
Yılmaz Sezgin, İsmail G. Kalaycı
● Evaluation of Serum Magnesium Levels in Patients with Hypertension: A Case-control Study 9
Ihor Prykhodko, Yanina Matsegora, Oleksandr Kolesnichenko, Serhii Voloshko, Viktoriia Vintoniak, Nataliya
Vasyukova, Liudmyla Budahiants, Viktoriia Kuzina, Serhii Motyka
● Combat Stress in Military Personnel: Theory, Genesis, Prevention, and Control 15
Ehsan Nazari, Hojjat Sayyadi, Fathola Mohamadian, Sehat Aibod, Ali Sahebi, Maryam Kheiry, Yousef Veisani
● A Survey on Mental Health Status in West of Iran: A Spatial Analysis 25
Elnaz Ashrafi, Farbod E.F. Azar, Morteza Mansourian, Fereshteh Osmani
● Investigating the Predictive Power of the Theory of Planned Behavior on the Behavioral Intention of
Healthy Eating in Adolescents 31
Octavian Vasiliu, Andrei G. Mangalagiu, Bogdan M. Petrescu, Cristian A. Cândea, Corina Tudor, Cristina F.
Pleșa, Diana G. Vasiliu, Cristian Năstase, Carmen A. Sirbu
● A Conceptual Analysis of Post-psychotic Depression 36
Mehmet E. Yuksel, Nazan H. Selmi, Caglayan M. Ayaz, Seval Izdes
● Evaluation of Adsorption Therapy as an Extracorporeal Blood Purification Technique in Critically Ill Covid-
19 Patients 46
Yanina Matsegora, Oleksandr Kolesnichenko, Ihor Prykhodko, Viktoriia Kuzina, Vitalii Panok, Andrii
Pashchenko, Serhii Shandruk, Natalia Penkova, Stanislav Larionov
● Psychometric Properties of the Method "Evaluation of Negative Mental Reactions and States of
Combatants" and Experience of its Application in Short-term Psychological Recovery 54
Cristina G. Dascălu, Magda E. Antohe, Raluca S. Costache, Victor L. Purcărea
● Associations Between Medical Students' Opinions on Usage of Internet Services and Digital Teaching
Tools 66
Adina Geambaşu, Remus R. Glogojeanu, Lucian G. Eftimie
● The Impact of Physical Therapy on Psychomotor Functions in a Patient with Systemic Lupus
Erythematosus and Diabetes Mellitus 74

Guidelines for authors 86

1
2
 https://doi.org/10.55453/rjmm.2024.127.1.1
The article was received on July 28, 2023, and accepted for publishing on September 28, 2023.
ORIGINAL ARTICLE

The Impact of Total Synovectomy on Blood Loss and Knee Function. A Prospective
Randomized Study

Mihnea A. Petre1, Mihai E. Gherghe1, Dragoș C. Cotor1, Alexandru Luchian1,2, Liliana L. Preotescu3,4, Cristian Scheau5,6, Romică
Cergan6,7
1 Department of Orthopaedics, “Foișor” Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, Bucharest, Romania
2 Department of Orthopaedics and Traumatology, The “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
3 Department of Infectious Diseases I, Faculty of Medicine, The “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

4 “Prof. Dr. Matei Balș” National Institute for Infectious Diseases, Bucharest, Romania

5 Department of Physiology, The "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania

6 Department of Radiology and Medical Imaging, “Foișor” Clinical Hospital of Orthopaedics, Traumatology and Osteoarticular TB, Bucharest, Romania

7 Department of Anatomy, The “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

Correspondence: Cristian Scheau, [email protected]

Abstract: Synovial proliferation is a common intraoperative finding during total knee arthroplasty (TKA) and many studies have
proposed synovectomy for the reduction of postoperative pain. We included 180 patients that were split into two groups, one
which received a total synovectomy (TS) and the other with partial synovectomy (PS). We measured the amount of intra- and
post-operative bleeding as well as perceived pain (using the Visual Analogue Scale) and knee function (using the Knee Society
Knee Score) at 4 and 12 weeks. The blood loss during the surgical procedure was 367.77 ± 115.71 mL for TS, while the other group
recorded 295.55 ± 106.17 mL (p < 0.05). Regarding postoperative bleeding, the TS group aspirated 533.77 ± 281.65 mL, which
was significantly higher than the PS group (404.44 ± 211.55 mL, p < 0.05). No significant differences were recorded between the
TS and PS groups regarding pain and knee function at 12 weeks. Total synovectomy demonstrated significantly higher blood loss
and lower postoperative hemoglobin levels, even though knee function and pain level did not show improvements. We consider
that the decision of performing synovectomy should rely on the clinical indication and, if conditions allow for it, a limited resection
should be attempted.

Keywords: synovectomy; total knee arthroplasty; osteoarthritis; therapeutic method; pathophysiology; surgical technique; joint
replacement

INTRODUCTION [6,7]. This intervention is typically reserved for individuals who

experience severe, persistent pain and mobility issues that
Osteoarthritis is common in the elderly population and is the
cannot be adequately addressed through more conservative
most frequent condition affecting the synovial joints,
interventions such as anti-inflammatory medications or
especially the knee. Restricted range of motion, discomfort,
physical therapy. In advanced osteoarthritis, patients
and local pain are the main symptoms deriving from
experience continuous pain that is unresponsive to typical
progressive cartilage deterioration of the articular surface of
anti-inflammatory medications, and radiographic imaging
the knee joint [1,2]. A decisive role in cartilage degrading is
shows a narrowing of the joint space and the formation of
played by chronic inflammation of the synovial membrane,
bony growths known as osteophytes [8].
known as synovitis [3,4]. Furthermore, residual synovial tissue
can be associated with postoperative impingement and During total knee arthroplasty, surgeons often identify
decreased range of motion [4,5]. synovial proliferation in patients with osteoarthritis or other
inflammatory conditions [3,9-11]. This proliferation of the
Total knee arthroplasty (TKA) is regarded as a radical effective
synovial membrane can contribute to inflammation and
treatment for patients with end-stage knee osteoarthritis

3
cartilage degradation, leading to decreased joint function and conducted by international ethical standards and the 1964
increased pain. Surgical synovectomy involves excising the Helsinki Declaration.
proliferated synovial membrane and was shown to improve
A radiological assessment was performed using plain X-rays,
joint function and reduce pain in patients with osteoarthritis
including an anteroposterior, lateral, and full weight-bearing
[3,9,10]. However, while this procedure can be effective in
lower limb, to develop proper preoperative digital planning.
reducing pain and inflammation, it also carries risks and
potential complications that need to be carefully evaluated on 2. Surgical Technique
a case-by-case basis.
All TKA procedures were performed according to a standard
Usually, the surgeon opts for the type of synovectomy protocol by a single highly experienced orthopedic surgeon in
depending on intraoperative assessment or personal our institution, specialized in TKA. The implant of choice was
preferences. Therefore, some surgeons perform total the Zimmer Biomet NexGen implant system. Preoperatively, 1
synovectomy as a mandatory step in the surgical technique of g of tranexamic acid was administered to all cases, and an
total knee arthroplasty, while other surgeons rather avoid additional 1 g after the procedure. All patients received spinal
performing total synovectomy because they consider it a anesthetic with a femoral nerve block. A tourniquet was
substantial factor in postoperative bleeding [12-14]. Some installed after three minutes of elevating the lower limb and
researchers suggested that total synovectomy influences was inflated up to 320 mm Hg before the incision and deflated
postoperative blood loss and operative time without being after the implantation to perform hemostasis. We used a
beneficial in terms of postoperative pain and knee function midvastus approach, an extramedullary tibial guide, an
[12,15]. intramedullary femoral guide, and a measured resection
technique. Wound closure was performed in a layered fashion
Decreasing postoperative discomfort and pain is essential to
and all patients received a deep drain. The drain was clamped
achieve a fast and efficient recovery and to improve the
for three hours and then released and removed 24 hours after
patient’s living quality [16,17]. The primary objective of this
surgery. The rehabilitation protocol was similar for both
study is to assess the influence of synovectomy performed
groups and began on the first day after surgery. Physical
during total knee arthroplasty for knee osteoarthritis on blood
therapy was continued either at home or in a specialized clinic.
loss, postoperative pain, knee range of motion, and function.
All cases received Heparin for deep vein thrombosis
prophylaxis for 30 days.
MATERIALS AND METHODS
We recorded preoperative data, which included age, gender,
1. Study design
knee range of motion, hemoglobin values, bleeding, and
We conducted a prospective single-center randomized comorbidities. Knee function was measured using the Knee
controlled trial between January 2022 and June 2022. A total Society Knee Score (KSKS). The amount of bleeding was
of 180 patients were included and split into two even groups, assessed by measuring the postoperative hemoglobin and
one which received a total synovectomy (TS) and another with bleeding during and after the surgery. Intraoperatively we
partial synovectomy during total knee replacement (PS). The measured the amount of blood aspiration by taking into
randomization was performed by an independent doctor using account the amount of physiological serum used for lavage
sealed envelopes. The envelopes were stored in a box. The and the operative time. After the surgical procedure, we
envelopes were drawn before surgery and contained measured the amount of blood aspirated through the drains
instructions regarding the surgical technique. and hemoglobin. All complications were recorded throughout
the study. For the functional evaluation, we measured flexion,
The inclusion criteria were patients with late-stage knee
extension, the Visual Analogue Scale (VAS), and KSKS score
arthritis. We excluded from our study patients with revisions
after 4 and 12 weeks. A blind independent observer evaluated
and cases requiring a more significant constraint than a
all the measurements.
posterior stabilized TKA (constrained or hinged knee). We also
excluded patients with acute coronary diseases, neurological 3. Outcome measures
diseases, infectious conditions, coagulation disorders, and a
The Visual Analogue Scale is a measure used to evaluate the
history of deep vein thrombosis or pulmonary embolism.
patient’s perspective of pain level. It may be dependent on the
This paper was approved by the “Foisor” Orthopaedics Clinical patient’s mental status but is very frequently used to correlate
Hospital Ethics Committee of Bucharest, Romania, approval with knee function evaluation [17,18].
number 6384/2021. Written informed consent was obtained
The KSKS contains questions in 2 sections: knee score (pain,
from all patients included in this study. The procedures were
range of motion, stability) and function (walking distance,

4
ability to climb stairs, walking aids) [19]. Both measures were RESULTS
provided to patients for answering in the hospital and during
We recorded 180 cases split into two even groups. The patient
follow-up visits.
characteristics are displayed in Table 1.
4. Statistical analysis
The blood loss measured during the surgical procedure was
All values were calculated as mean values ± standard 367.77 ± 115.71 mL for the total synovectomy, while the
deviation. The statistical analysis was developed using the second group recorded 295.55 ± 106.17 mL of blood loss (p <
Student t-test and Mann-Whitney U test for comparison 0.05). Regarding postoperative bleeding, the TS group
between groups. A p-value lower than 0.05 was considered aspirated 533.77 ± 281.65 mL, which was significantly higher
statistically significant. The data was analyzed for Windows OS than the PS group, where we recorded an aspiration of 404.44
using SPSS version 28.0 (SPSS Inc., Chicago, IL). ± 211.55 mL (Table 2).

Table 1: Baseline characteristics of the study groups

Total synovectomy Partial synovectomy p-value
Age (years) 70.41±7.25 70.8±7.23 0.71
Gender (M/F) 41/49 44/46 0.77
Preoperative hemoglobin (g/dL) 13.24±1.22 13.22±1.18 0.90

Table 2: Postoperative parameters of the study groups

Total synovectomy Partial synovectomy p-value
Intraoperative bleeding (mL) 367.77±115.71 295.55±106.17 <0.05
Postoperative bleeding (mL) 533.77±281.65 404.44±211.55 <0.05
Postoperative hemoglobin (g/dL) 11.43±1.26 11.88±1.22 <0.05
VAS1 score (4 weeks) 3.39±1.50 3.79±1.32 0.058
VAS score (12 weeks) 1.3±1.01 1.41±0.89 0.43
KSKS2 score (4 weeks) 82.28±4.09 82.42±4.46 0.83
KSKS score (12 weeks) 87.9±3.7 88.33±4.11 0.47
Operating Room time (min.) 96.5±7.93 92.2±6.37 <0.05
1 VAS=Visual Analogue Scale; 2 KSKS=Knee Society Knee Score

The mean preoperative hemoglobin was 13.24 ± 1.22 g/dL for partial synovectomy group.
the TS group and 13.22 ± 1.18 g/dL for the PS group (p = 0.90).
We recorded wound complications in three cases in the first
Postoperatively, a statistically significant decrease was
group and two patients in the second group. Also, we noticed
recorded in the two groups, the hemoglobin dropping to 11.43
hemarthrosis following drain removal in 20 cases that
± 1.26 g/dL and 11.88 ± 1.22 g/dL, respectively, (p < 0.05).
underwent total synovectomy and 5 cases with partial
However, after four weeks, the VAS score was 3.39 ± 1.50 in
synovectomy.
the TS group and 3.79 ± 1.32 in the PS group, while KSKS was
82.28 ± 4.09 and 82.42 ± 4.46, respectively. Both scores’
DISCUSSION
differences between groups were not significant. At the three
months follow-up, both parameters showed improvements for The synovial tissue is regarded as a critical component in the
both groups. VAS score was 1.3 ± 1.01 for the TS group, while locomotor function [20,21]. The synovial tissue of the knee
PS patients had a score of 1.41 ± 0.89. (p = 0.43) KSKS score joint plays multiple roles, including the secretion of synovial
showed no statistically significant differences after three fluid that lubricates the joint, providing nutrients to the
months, the results being 87.9 ± 3.7 and 88.33 ± 4.11, articular cartilage, protection against infection, and removal of
respectively (p = 0.47). However, we recorded significant waste products from the joint. The aforementioned functions
differences regarding the operative room time between are responsible for the maintenance of the health and proper
groups: 96.5 ± 7.93 minutes for the TS group and 92.2 ± 6.37 functioning of the knee joint. On the other hand, progressive
minutes for the PS group, respectively (p < 0.05). joint degeneration, which leads to osteoarthritis, is caused by
the involvement of bone, cartilage, and synovial pathological
Regarding complications, we recorded 7 cases of deep vein
processes [21,22]. For this reason, synovectomy is performed
thrombosis in the total synovectomy group and 5 cases in the
to relieve pain or to attempt the prevention of cartilage and/or

5
bone destruction and to improve knee function [23,24]. osteoarthritis [32,33]. Even though synovectomy reduces knee
pain, especially in cases with pathological synovial tissues, the
During a total knee arthroplasty, total synovectomy may be
VAS score in our study did not show any significant differences
performed for different reasons. One reason is to remove any
during the follow-ups. Also, the KSKS score showed no
inflamed or diseased synovial tissue that may be present in the
significant differences after 4 weeks or after 12 weeks. This
joint, with the aim of improving joint function and reducing
result is also reported by other authors who also recorded
pain and inflammation. Another reason is to prevent the
increased concealed bleeding, higher drainage, and longer
formation of a pseudo capsule, a thick layer of scar tissue that
operative time in patients that underwent total synovectomy
can form around the artificial joint and cause complications.
[12]. Moreover, similar studies evaluating the quality of life
However, total synovectomy may also have drawbacks, such
and complications recorded no significant improvements
as an increased risk of infection and reduced lubrication and
regarding these parameters [34].
nutrition of the articular cartilage [21,22]. The decision to
perform a total synovectomy during a total knee arthroplasty Literature data have indicated that total synovectomy during
should be taken individually, for each patient, by weighing the total knee arthroplasty may be linked to an increased
potential benefits and risks. Furthermore, proper planning of incidence of certain complications such as deep vein
the procedure is essential to ensure shorter operating times thrombosis, hemarthrosis, and wound complications
and faster recovery; this includes digital radiological planning, [12,21,33-37]. However, it is essential to note that the
choosing the ideal implant type and model, and controlling the available data is currently limited. Therefore, additional
patient risk factors [25-27]. investigations with a larger sample size are required to
establish a more robust statistical correlation on this subject.
Our study aimed to evaluate the influence of synovectomy on
Despite this observation, it should be noted that individual
postoperative results and blood loss following total knee
patient characteristics and other factors may also contribute
replacement. The intraoperative and postoperative blood loss
to the occurrence of these complications.
was found to be significantly higher after total synovectomy
compared to the partial synovectomy group. We found One major limitation of our study is that it was conducted in a
variable results regarding average blood loss in the literature, single center, which may limit the generalization of our results
which ranged between 300 and 2500 mL [12,28-30]. This to other study populations. Additionally, we did not evaluate
variability may be explained by the different surgical hematocrit levels or blood transfusion requirements, which
techniques, thromboprophylaxis treatments, or implant types are important factors that could reveal further associations
that were applied. In our paper, the total synovectomy group between total synovectomy and blood loss. Furthermore, we
had a blood loss from drains of 533.77 ± 281.65 mL for the total acknowledge that more extended follow-up periods could be
synovectomy group compared to the second group, which had beneficial in the thorough evaluation of the functional
404.44 ± 211.55 mL blood loss. We consider this to be one of outcomes and risk of synovial recurrences associated with
the main reasons behind the preference of some surgeons to total synovectomy during total knee arthroplasty. Additionally,
avoid total synovectomy. it is important to note that our study did not assess the risk of
other potential complications that could arise from this
Our study also revealed a significantly lower postoperative
procedure. Therefore, while our study provides important
hemoglobin level after synovectomy. This result was also
insights into the potential risks and benefits of total
recorded in other papers [12,21,31]. However, some studies
synovectomy during total knee arthroplasty, additional
concluded that even though the bleeding rates are higher, the
research with a larger sample size and more extended follow-
blood transfusion threshold is not reached when total
up periods are needed to fully understand the implications of
synovectomy is performed, therefore the two surgical
this procedure for patients undergoing knee arthroplasty.
techniques do not yield statistically significant differences in
this regard [15,21].
CONCLUSIONS
Another significant result of this study was that total
Patients with total synovectomy associated with total knee
synovectomy demonstrated some postoperative
arthroplasty experienced a notably more significant amount of
improvements but these were not statistically significant
blood loss and lower postoperative hemoglobin levels than the
compared to the other group and did not show any differences
control group. However, no statistically significant differences
regarding pain relief, despite the considerable blood loss
were observed between the two groups in terms of knee
difference. It is well known that the synovium, as well as other
function and pain level. Further multicenter studies with
articular structures like muscles, joint capsules, or ligaments,
longer follow-up times are required to more comprehensively
is well-innervated and could be a source of pain in
assess the potential complication rate and risk of synovial

6
recurrence associated with total synovectomy during total intellectual content. C.S. and R.C. contributed to the writing of the manuscript
knee arthroplasty. Ultimately, more comprehensive research and performed revision, language, and textual editing of the final version. All
authors contributed to the original draft preparation of the manuscript. All
is required to determine the optimal approach to synovectomy authors have read and agreed to the published version of the manuscript.
and to provide the most beneficial outcomes for patients
undergoing total knee arthroplasty. Patient consent for publication
Informed consent was obtained from all subjects involved in the study.

Conflicts of interest and sources of funding Ethics approval and consent to participate
The authors declare no conflict of interest. This research received no external All procedures performed in this paper were by the 1964 Helsinki Declaration and
funding. its later amendments or comparable ethical standards and according to the
national ethical standards. The study received approval from the “Foisor”
Authors’ contribution Orthopaedics Clinical Hospital Ethics Committee of Bucharest, Romania,
M.-A.P. and L.L.P. planned the clinical study and contributed to the concept and approval number 6384/2021 (date of approval 10th of December 2021).
design of the study. M.E.G., D.C.C., and A.L. contributed to the data analysis and Informed consent was obtained from all individual participants included in the
interpretation as well as to the translation and the critical revision of important study.

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 https://doi.org/10.55453/rjmm.2024.127.1.2
The article was received on April 5, 2023, and accepted for publishing on August 7, 2023.
ORIGINAL ARTICLE

Evaluation of Serum Magnesium Levels in Patients with Hypertension: A Case-control Study

Yılmaz Sezgin1, İsmail G. Kalaycı2

1 Department of Family Medicine, Istanbul Training and Research Hospital, Istanbul, Turkey; [email protected]
2 Department of Family Medicine, Istanbul Training and Research Hospital, Istanbul, Turkey; [email protected]

Correspondence: Yılmaz Sezgin, [email protected]

Abstract: There are conflicting data on the effects of magnesium on hypertension in the literature. Therefore we aim this study
to investigate whether there is a relationship between serum magnesium levels and hypertension in newly diagnosed. This is a
case-control study. The patients were selected from the records of patients who applied to the family medicine outpatient clinic
between June 2016 and May 2017. A total of 276 patients, 68 patients with newly diagnosed hypertension in the case group and
208 patients without any disease in the control group were included in the study. Binary logistic regression analysis was
performed between the case and control groups. The odds ratio for magnesium was 0.1 (0.012-0.810). When the value of the
magnesium variable increases by 1mg/dl, the risk of hypertension decreases by 90%. However, in the presence of magnesium as
an independent variable, the predictability rate of our model was expected to increase but decreased. The odds ratio for age was
1.14 (1.092-1.186). The odds ratio for exercise was 0.18 (0.03-0.99). The odds ratio for glucose was 1.03 (1.001-1.065). In our
study that magnesium deficiency causes an increased risk of hypertension, the predictability rate of our model was expected to
increase instead of decrease. These findings show that a cause-effect approach or incidental association cannot explain the
relationship between magnesium and hypertension.

Keywords: hypertension; magnesium; age; exercise; glucose

INTRODUCTION muscular excitability, muscle contraction, and hormone

secretion [6]. Given the role of magnesium in calcium and
The prevalence of hypertension continues to increase globally
potassium transport, cell signaling, energy metabolism,
[1]. The prevalence of hypertension in the adult population in
genome stability, DNA repair, and replication, it should be
the world is 31% [2]. For over forty years, the causes of most
expected that hypomagnesemia is associated with many
hypertensive diseases have been unknown and are defined as
diseases, including neurological disorders, osteoporosis,
primary or essential hypertension. Secondary causes are
diabetes, coronary heart disease, and hypertension [7].
accepted as 5-10% [3].
Magnesium levels were lower in white hypertensives than in
Recently, risk factors such as age, sex, race, family history,
normotensives, while no significant difference was found in
genetic composition, obesity, excessive salt intake, inactivity
black hypertensives compared to normotensives [8]. It has
or lack of exercise, high-fat diet, tobacco use, and alcohol
been shown that those with essential hypertension have a
consumption have been proven to lead to the development of
significantly higher intra-erythrocytic magnesium level than
hypertension [4].
healthy individuals [9]. A systemic review and meta-analysis
Magnesium (Mg) can be found in the fourth sequence in the study suggested no relationship between serum magnesium
human body and the second after potassium in the and hypertension but that dietary magnesium
intracellular area [5]. Magnesium is an essential cation playing supplementation reduces blood pressure [10]. Magnesium
a crucial role in many physiological functions. It is critical in deficiency was found to be responsible for calcium and
energy-requiring metabolic processes, protein synthesis, magnesium disorders in those with pregnancy-induced
membrane integrity, nervous tissue conduction, neuro- hypertension, and magnesium sulfate therapy was effective in

9
these patients [11]. In a meta-analysis of twelve studies, a Inclusion and exclusion criteria
reduction in diastolic blood pressure was observed, while a
Among the patients tested for magnesium at the time of
decrease in systolic blood pressure was not observed [12].
admission, patients with hypertension newly diagnosed were
Again, a meta-analysis of 20 studies found a reduction in
included in the case group, and those with no chronic disease
systolic blood pressure while no change in diastolic blood
and no medication were included in the control group. The
pressure [13]. A meta-analysis of 22 studies noted a reduction
study did not include those with any illness and drug use
in both systolic and diastolic blood pressure [14].
before the application, those with a previous hypertension
The fact that there are conflicting data on the effects of diagnosis and treatment, and those without magnesium
magnesium on hypertension in the literature shows a need for checked at the time of application.
research on this subject. For this purpose, we wanted to
Statistical analysis
evaluate magnesium levels in patients with newly diagnosed
hypertension. This study aims to investigate whether there is All statistical analyses were performed using IBM SPSS
a relationship between serum magnesium levels and Statistics (V25). A P-value below 0.05 was considered
hypertension. statistically significant. In the data expression, categorical
data, numbers and percentages, and numerical data were
MATERIALS AND METHODS expressed with averages and standard deviation. The
distribution of demographic data was analyzed by frequency
Study Design
tests, comparison of categorical data by chi-square test, and
This study is a case-control study. The sample size was comparison of numerical data by independent sample t-test.
determined for logistic regression analysis, considering the The stepwise enter model was used in the binary logistic
number of seven independent variables, such as age, gender, regression test to evaluate the effect of magnesium on
body mass index (BMI), smoking, alcohol consumption, hypertension. Skewness and kurtosis analyses were used to
exercise status, and magnesium. For each group, using the conform the data to the normal distribution.
power analysis method, the minimum sample size of at least
Ethical Considerations
48 which is needed to detect a significant difference when
taken into account at 0.05 type-I error (Alpha), 0.35 effect size, Ethical approval was obtained from the İstanbul Training
0,80 power (1-beta). Research Hospital Clinical Research Ethics Committee
(Decision no. 14.10.2022, 318).
Population selection

The patients included in the study were selected from those RESULTS
who applied to the family medicine outpatient clinic between
A total of 276 people, including 68 cases and 208 control
June 2016 and May 2017 from the hospital information system
groups, were included in the study. There was no found
and patient records. Sixty-eight people with hypertension
difference between those with hypertension and those
constituted the case group. Two hundred-eight people
without it in terms of sex, smoking, and alcohol consumption.
without hypertension formed the control group. The control
However, the proportion of those without exercise was found
group was selected considering demographic characteristics
to be lower in the hypertension group (Table 1).
such as age and gender.

Table 1: Comparison of the case and control groups in terms of gender, smoking, alcohol consumption, and exercise status
Characteristics of Hypertension N (%)
participants No Yes Total p
Women 149 (71.6) 52 (76.5) 201 (72.8)
Gender 0.530
Men 59 (28.4) 16 (23.5) 75 (27.2)
No 167 (80.3) 58 (85.3) 225 (81.5)
Smoking 0.472
Yes 41 (19.7) 10 (14.7) 51 (18.5)
No 204 (98.1) 68 (100.0) 272 (98.6)
Alcohol 0.575
Yes 4 (1.9) 0 (0.0) 4 (1.4)
No 168 (80.8) 66 (97.1) 234 (84.8)
Exercise < 0.001*
Yes 40 (19.2) 2 (2.9) 42 (15.2)
Chi-Square Tests: The statistically significant difference was accepted as p < 0.05

10
The average age and BMI were found to be higher in the group increased in the case group. Magnesium levels were found to
with hypertension. Additionally, glucose, total cholesterol, be higher in the control group than in the case group (Table 2).
triglycerides, and LDL- cholesterol (LDL-C) were found to be

Table 2: Comparison of case and control groups in terms of age, body mass, and biochemical parameters
Hypertension
No Yes
Mean ± SD t. p
Glucose (mg/dl) 95.25 ± 11.04 107.79 ± 15.96 -6.02 < 0.001*
Cholesterol (mg/dl) 206.55 ± 44.32 229.43 ± 35.59 -3.86 < 0.001*
Triglycerides (mg/dl) 111.96 ± 61.58 154.07 ± 60.27 -4.92 < 0.001*
HDL-C (mg/dl) 54.55 ± 12.66 52.68 ± 7.40 1.49 0.137
LDL-C (mg/dl) 129.35 ± 37.07 143.49 ± 29.66 -3.19 0.002*
Calcium (mg/dl) 9.47 ± 0.46 9.54 ± 0.43 -1.11 0.266
Magnesium (mg/dl) 1.99 ± 0.19 1.92 ± 0.15 2.82 0.005*
Sodium (mmol/L) 139.14 ± 1.99 145.24 ± 32.97 -1.52 0.133
TSH (mIU/L) 1.91 ± 1.29 1.90 ± 1.20 0.06 0.950
Vitamin B12 (ng/L) 231.69 ± 127.26 207.32 ± 90.38 1.73 0.085
Vitamin D (ng/ml) 20.08 ± 10.69 19.32 ± 9.60 0.52 0.602
Age (years) 39.69 ± 12.80 59.71 ± 11.65 -11.42 < 0.001*
BMI 25.83 ± 4.48 29.50 ± 6.25 -4.47 < 0.001*
SD: Standard Deviation; BMI: Body Mass Index; *Independent sample t-test is significant at the 0.05 level (2-tailed)

Binary logistic regression analysis was performed by Snell R2 and Nagelkerke R2 values are smaller than the 0.2
considering the different parameters between the case and value. However, the model is significant when other
control groups. In addition to the magnesium, age, exercise, independent variables are added. Except for the step in which
BMI, glucose, triglyceride, and LDL-C variables which were triglyceride was added, the model’s goodness of fit is
different between the case and control groups, gender and acceptable since the p-values are bigger than 0.05 in the
sodium variables were also included in the analysis according Hosmer-Lemeshow test. Changes in -2 Log Likelihood values
to the literature [4]. Total cholesterol was not included in the (Chi-square, p < 0.05) are significant in magnesium, age,
study because it is affected by LDL-C and triglyceride. exercise, and glucose steps.

In the analysis in which only magnesium as an independent These results show that the logistic regression analysis is
variable was added, the model is insignificant because the Cox- generally valid (Table 3).

Table 3: Distribution of data showing the validity of the logistic regression analysis

Metod=Enter: -2 Log Cox and Snell Nagelkerke R Hosmer and Predicted

Chi-square P
stepwise Likelihood R Square Square Lemeshow Test percentage

Beginning 308.192 75.4

+ Magnesium 299.999 8.193 0.004* 0.029 0.043 0.150 74.6
+ Age 194.958 105.041 < 0.001* 0.337 0.500 0.493 82.6
+ Exercise 186.608 8.350 0.004* 0.356 0.530 0.642 81.9
+ Gender 186.341 0.267 0.606 0.357 0.531 0.592 81.9
+ BMI 183.822 2.519 0.112 0.363 0.539 0.695 83.3
+ Glucose 179.281 4.541 0.033* 0.373 0.555 0.398 84.1
+ Triglycerides 179.265 0.015 0.901 0.373 0.555 0.044* 83.3
+ LDL-C 178.064 1.201 0.273 0.376 0.559 0.744 82.6
+ Sodium 178.059 0.005 0.944 0.376 0.559 0.746 82.6
*The statistically significant difference was accepted as p < 0.05

11
The odds ratio for magnesium was found to be 0.1 (0.012- those with non-exercise, the risk of hypertension was found to
0.810). When the value of the magnesium variable increases be 82% less in those with exercise. The odds ratio for glucose
by 1mg/dl, the risk of hypertension decreases by 90% (Table was found to be 1.03 (1.001-1.065). When the value of the
4). However, in the presence of magnesium as an independent glucose variable increases by 1 mg/dl, the risk of hypertension
variable, the predictability rate of our model was expected to increases by 1.03 times (Table 4).between vitamin D and total
increase but decreased (Table 3). The odds ratio for age was cholesterol and LDL-C in the young age group. However, serum
found to be 1.14 (1.092-1.186). When the value of the age vitamin D had no significant correlation with serum glucose,
variable increases by one unit, the risk of hypertension triglyceride, HDL-C, calcium, magnesium, sodium, TSH levels,
increases by 1.14 times. The odds ratio for exercise was found and BMI scores (Table 4).
to be 0.18 (0.03-0.99). When the reference group is taken as

Table 4: Logistic regression analysis showing the relationship between hypertension and variables of magnesium, age, exercise, gender, BMI,
glucose, triglyceride, LDL-C, and sodium
Risk (Odds) 95% C.I.for (Exp B)
Hypertensiona B SE Wald P
coefficient Lower Upper
Magnesium (mg/dl) -2.325 1.079 4.645 0.031* 0.1 0.012 0.810
Age (years) 0.129 0.021 37.532 < 0.001* 1.14 1.092 1.186
Exercise (1: -/+) -1.723 0.874 3.882 0.049* 0.18 0.032 0.991
Gender (1: Women/Men) -0.628 0.456 1.898 0.168 0.53 0.219 1.304
BMI 0.031 0.040 0.621 0.431 1.03 0.955 1.115
Glucose (mg/dl) 0.032 0.016 4.140 0.042* 1.03 1.001 1.065
Triglycerides (mg/dl) 0.001 0.003 0.019 0.890 1.00 0.994 1.007
LDL-C (mg/dl) -0.006 0.006 1.172 0.279 0.99 0.983 1.005
Sodium (mmol/L) 0.002 0.034 1.897 0.947 1.00 0.938 1.071
aDependent Variable: Hypertension; BMI: Body Mass Index; B: Estimated Coefficients; CI: Confidence Interval; SE: Standard Error; *Logistic regression analysis is
significant at the p < 0.05 level (2-tailed)

DISCUSSION number of participants in meta-analysis studies is high, it is a

point that should not be overlooked that statistical significance
The fact that the age and BMI values, glucose, total
will be high, even if there is no significance in reality.
cholesterol, triglycerides, and LDL-C levels are high in those
with hypertension and the low rate of exercisers shows that In our study, it was found that when the value of the age
the study groups are compatible with the general population. variable increased by one unit, the risk of hypertension
increased by 1.14 times. In our working model, the probability
In our study, magnesium levels were lower in those with
of predicting hypertensive patients in the presence of
hypertension. When the value of the magnesium variable
magnesium and age is relatively high. This result indicates that
increases by 1mg/dl, the risk of hypertension decreases by
the age variable is an important risk factor. In the literature,
90%. However, in the presence of magnesium as an
age is recognized as a risk factor for hypertension [4]. Studies
independent variable, the predictability rate of our model for
have been reported showing that magnesium decreases with
hypertensive patients decreased, while it was expected to
age [20,21]. It has been suggested that this relationship may
increase [2]. In two meta-analysis studies involving seven and
be related to decreased absorption with age and slower kidney
11 studies, it has been suggested that magnesium
reabsorption [22,23]. In addition, recent reports indicate that
supplementation provides a significant, albeit small, decrease
many Americans, especially older people, do not consume the
in blood pressure [15,16]. In a meta-analysis in which thirty-
recommended daily amount of magnesium [24]. In countries
four studies were evaluated, it was found that there was a
with high incomes, the rate of hypertension is lower than in
decrease in both systolic and diastolic blood pressure [17]. A
poor countries [2]. Again, it is stated that an unhealthy diet
recent meta-analysis study claimed that oral magnesium
causes hypertension [25]. All these findings and literature
supplementation does not affect blood pressure in
information suggest that the relationship between magnesium
normotensives and controlled hypertensives but reduces
and hypertension may be an incidental association.
blood pressure in uncontrolled hypertensives [18]. In addition,
there was no difference in magnesium levels between those Our study found that the risk of hypertension decreased by
with hypertensive crisis and the control group [19]. However, 82% in those who exercised. In the literature, it is accepted
in light of these contradictory findings, considering that the that inactivity or lack of exercise is a risk factor for

12
hypertension [4]. It is stated that regular exercise causes a been emphasized [37]. Both magnesium deficiency and
decrease in blood pressure of 5 mmHg [26]. In addition, oxidative stress have been identified as pathogenic factors in
emphasis has been placed on the curative effect of both aging and age-related diseases. Additionally, severe
aerobic and moderate-weight exercise on hypertension [27]. magnesium deficiency has been shown to increase oxidative
Aerobic exercise is assumed to positively affect hypertension stress in experimental animals [38]. In light of these findings, it
by reducing oxidative stress [28]. A recent meta-analysis seems complicated to define the relationship of magnesium
indicates that aerobic exercise is an effective adjunctive with hypertension without fully elucidating the complex
treatment method for lowering ambulatory blood pressure in effects of oxidative stress on hypertension.
hypertension patients receiving drug therapy [29].
CONCLUSIONS
Our study found no relationship between body mass index and
hypertension. However, when the value of the glucose As a result, it was found in our study that magnesium
variable increased by one unit, the risk of hypertension deficiency causes an increased risk of hypertension. However,
increased 1.03 times, albeit very slightly. Obesity is accepted in the presence of magnesium as an independent variable, the
as a risk factor for hypertension in the literature [4,30]. predictability rate of our model was expected to increase but
Mechanisms of obesity causing hypertension are explained by decreased. These findings show that the relationship between
the activation of the sympathetic nervous system activated by magnesium and hypertension cannot be explained only by a
hormones such as leptin, insulin, melanocortin, and the cause-effect connection or incidental association. This may
activation of the renin-angiotensinogen system due to explain the reason for the conflicting results in the literature.
oxidative effects caused by proinflammatory cytokines More detailed analyzes are needed in this regard.
released as a result of dyslipidemia [31]. Many
pathophysiological mechanisms explain the relationship Conflicts of interest and sources of funding
between diabetes and hypertension. These mechanisms are The authors declare no conflict of interest. The funders had no role in the design
mainly hyperinsulinemia-mediated sympathetic activation, of the study; in the collection, analyses, or interpretation of data; in the writing
of the manuscript; or in the decision to publish the results. This research received
hyperglycemia-induced sodium-fluid retention, the
no external funding.
stimulatory effect of hyperglycemia on the renin-angiotensin-
aldosterone system, and increased insulin resistance as a Authors’ contribution
result of oxidative stress [32,33]. All authors made substantial contributions to the conception or design of the
work or the acquisition, analysis, or interpretation of data for the work. All
An increased risk of type-2 diabetes and increased LDL-C levels authors have read and agreed to the published version of the manuscript.
were found in low magnesium [34]. It has been suggested that
Patient consent for publication
the positive effects of magnesium on diabetes occur by
Because of the retrospective study, patient consent was not obtained.
inhibiting oxidative stress [35]. It is also stated that the primary
pathology in gestational hypertension in which magnesium Ethics approval and consent to participate
sulfate is used in the treatment is oxidative stress [36]. The Ethical approval was obtained from the İstanbul Training Research Hospital
Clinical Research Ethics Committee (Decision no. 14.10.2022, 318).
positive effects of regular and aerobic exercise on oxidative
stress and its curative effects on diabetes and obesity have

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 https://doi.org/10.55453/rjmm.2024.127.1.3
The article was received on April 23, 2023, and accepted for publishing on August 12, 2023.
REVIEW

Combat Stress in Military Personnel: Theory, Genesis, Prevention, and Control

Ihor Prykhodko1, Yanina Matsegora2, Oleksandr Kolesnichenko3, Serhii Voloshko4, Viktoriia Vintoniak5, Nataliya Vasyukova6,
Liudmyla Budahiants7, Viktoriia Kuzina8, Serhii Motyka9
1 Research Center, National Academy of National Guard of Ukraine, Kharkiv, Ukraine; [email protected]
2 Research Center, National Academy of National Guard of Ukraine, Kharkiv, Ukraine; [email protected]
3 Department of Professional Psychology, National Academy of the Security Service of Ukraine, Kyiv, Ukraine; [email protected]

4 Command and Staff Faculty, National Academy of National Guard of Ukraine, Kharkiv, Ukraine; [email protected]

5 Department of Social Sciences, National Defense University of Ukraine, Kyiv, Ukraine; [email protected]

6 Foreign Languages Training and Research Centre, National Defense University of Ukraine, Kyiv, Ukraine; [email protected]

7 Department of Social Sciences, National Defense University of Ukraine, Kyiv, Ukraine; [email protected]

8 Department of Social Sciences, National Defense University of Ukraine, Kyiv, Ukraine; [email protected]

9 Humanitarian Institute, National Defense University of Ukraine, Kyiv, Ukraine; [email protected]

Correspondence: Ihor Prykhodko, [email protected]

Abstract: On February 24, 2022, the Russian-Ukrainian war began, in which hundreds of thousands of military personnel are
participating. Almost all military personnel experience combat stress. In our opinion, the most fully reflecting the occurrence of
stress in humans, including combat stress in military personnel, is the conservation of resource theory proposed by S. Hobfoll.
According to this theory, stress occurs when: central or key resources (health, well-being, family, self-esteem, and a sense of
purpose and meaning in life) are threatened with loss, are lost, or cannot be retrieved following significant effort. Combat stress
in military personnel can manifest itself in the form of negative manifestations of the psychological, physical, psychophysiological,
and behavioral register. The most effective system for the prevention and control of combat stress among military personnel was
developed in the US Army. Such a program should contain medical and psychological work activities carried out in three stages:
preparatory (before performing combat missions), the stage of direct performance of tasks in the combat zone, and the final
stage (after completing tasks upon returning to permanent deployment points).

Keywords: stress, combat stress, military personnel, fighting, COSC

INTRODUCTION An analysis of scientific sources on the subject of combat stress

has shown that a lot of applied research has been carried out
There are few areas of contemporary psychology that receive
to solve this rather complex problem. This is because the last
more attention than stress [1,2]. This literature reflects
fifty years have been characterized by a significant increase in
researchers’ belief that stress is a major factor affecting
local and regional armed conflicts in the world [5-7]. The
people’s lives, is intimately tied to mental health, and is very
localization, time, nature, goals, the pace of hostilities, and
possibly linked with many problems of physical health [1]. The
military operations varied greatly during this period. But, as a
interest in stress has also caught the attention of the popular
rule, the majority of military personnel in their military career
press, illustrating that stress is of concern to the lay public as
took part only in a series of combat deployments [8].
well as the academic community [3]. However, despite the
breadth of interest in the problem of stress, there is little However, in the 21st century, not a single country, except
research to substantiate the relevant theories [2]. But in Ukraine, has faced the armed aggression of the Russian
psychology, as in other sciences, it is difficult to create a Federation, and a large-scale war has been going on for more
sincere body of knowledge without a clear theoretical than a year. Hundreds of thousands of troops from both sides
foundation, because there are no definite limits to the theory are taking part in the fighting. Almost all Ukrainian servicemen
that can be denied [4]. experience combat stress [9-11]. These circumstances, as well

15
as the duration and complexity of staying in extreme (combat) that a person can resist initial stressors of moderate strength
conditions, put forward high demands on the mental health, or lower-level negative factors that cause stress. However,
army values and motivation of military personnel, as well as on prolonged or more severe stressors will lead to disruption of
their psychological qualities and the adequacy of behavior for the body’s biological systems [36].
this activity [12-18]. Despite the high motivation to conduct
W. Cannon’s research on stress was continued and developed
combat operations, the improvement of military professional
by Hans Selye. He described stress as a reaction (organized
training and psychological preparation, some military
defense) of the body to non-specific harmful agents and called
personnel have problems with mental health, manifested by
it the “general adaptation syndrome” [37]. According to the
the development of acute stress reactions, post-traumatic
author’s definition, the general adaptation syndrome is the
stress disorders (PTSD), as well as addictive and delinquent
body’s response to severe damage by non-specific harmful
behavior, an increase in suicidal manifestations [19-25].
agents (for example, exposure to cold, surgical shock,
Similar mental, physical, and behavioral health problems have excessive physical exertion, or intoxication with sublethal
occurred in US and coalition forces during and after combat doses of various drugs) and it does not depend on the nature
deployments in Iraq and Afghanistan [5-7,26-30]. In of the damaging agent [37]. Thus, the protective role of the
combatants, these disorders manifested in persistent sleep general adaptation syndrome consisted in the formation of
disturbances, headaches, fatigue, and other symptoms nonspecific resistance of the organism to pathogenic agents,
associated with the influence of various stress factors in the regardless of their nature. The researcher believed that there
combat environment, as well as the occurrence of more is a response of the body to external factors, which go through
complex and severe disorders such as PTSD, traumatic brain three stages in succession: anxiety (anxious response),
injury and depression [31-33]. resistance, and exhaustion [38].

The conducted studies revealed that the significance of the Another direction in the study of the mechanisms of
influence on the psyche of military personnel and the development of stress has already taken into account not only
development of the consequences of experiencing combat responses to stressors but also directly stressful events, as well
stress were determined by: factors of the combat situation; as individual differences in their assessment. Spielberger
individual psychological characteristics of a person; the level of suggested that certain events are stressful if they are thought
professional and psychological preparation for the conduct of to be threats to the physical self or the phenomenological self
hostilities; the nature and level of motivation of military [39]. He proved that although individuals with different
personnel; the influence of combat stress factors on the personalities responded some-what uniformly to physical
further life of military personnel, etc. [9,20,28,34,35]. threats, people’s responses to ego-threats were related to
personality traits. In particular, Spielberger noted that people
The objective of this study
with high trait anxiety tended to react with state elevations in
The purpose of the article was to systematize scientific anxiety to ego-threat, whereas those who were low in trait
research on the problem of stress, combat stress, to study the anxiety tended to be comparatively impervious to ego-threats.
modern system of mental health care for military personnel of Thus, the researcher concluded that it is not the stimulus and
the leading NATO partner countries, and to determine the not the assessment that is important, but their specific
main directions for improving the Ukrainian system for the interaction. This three-step approach was a conceptual leap
prevention and control of combat stress among military for stress researchers but rarely followed up in further
personnel. research. Instead, many researchers have reverted to models
that only assessed stress, almost completely ignoring actual
BASIC STRESS THEORIES environmental or personality traits; others reflected only
personality characteristics, while others remained tied only to
All theories of stress, in particular, combat stress, are based
the model’s stimuli.
mainly on medical, biological, and psychological studies that
reflect the processes of a distinct reaction of the human body In modern studies of the problem of stress, the homeostatic
to stress. In general, the term “stress” was borrowed by and transactional models of stress are most often used. The
researchers from physics: it was previously believed that homeostatic model is presented in detail by McGrath [40] but
people are in some sense similar to physical objects, such as is based in large part on the work of Lazarus [41]. According to
metals, resisting moderate external forces, but losing their research results, McGrath proposed the definition of stress as
stability at some point of higher pressure [1]. Walter Cannon “a significant imbalance between the needs of the
was probably the first researcher to apply the concept of environment and the ability to respond to the body” [40, p.
“stress” to humans in these kinds of terms [36]. He concluded 17].

16
In 1966, the concept of cognitive appraisal was proposed by feeling that they are able to cope with stressful situations.
Richard Lazarus [41]. According to this theory, stress is
According to Hobfoll, a critical tenet conservation of resource
perceived as the imbalance between the demands placed on
theory is that individual value is secondary to what is most
the individual and the individual’s resources to cope [2]. The
valued and universal to people. Typically, these valuable
transactional model of stress and coping contended that a
resources are health, well-being, family, self-esteem, and a
person’s capacity to cope and adjust to challenges and
sense of purpose and meaning in life [42]. How these
problems is a consequence of transactions (or interactions)
evaluations are expressed may vary across cultural
that occur between a person and their environment. The
backgrounds but always reflects the same basic elements. The
authors defined stress as “a particular relationship between
conservation of resource theory, in general, explains the
the person and the environment that is appraised by the
mechanisms of development and transformation of the
person as taxing or exceeding his or her resources and
psychological safety of personality in military personnel during
endangering his or her well-being” [2, p. 19].
activities under different conditions [43].
However, according to Hobfoll, these models and their
definitions have a number of shortcomings [1]. First, the DEFINITION OF COMBAT STRESS
author notes, these definitions state that stress is not the
An analysis of scientific research has shown that there is no
product of an imbalance between objective demands and the
generally accepted definition of the “combat stress” construct:
ability to respond, but is the result of the perception of these
depending on the field of its study (medicine, biology,
factors. Secondly, the consequences of failure should be
psychology, sociology, other social sciences), there are many
perceived as very important for a person. Third, McGrath
definitions of this category. Specialists who study stress in
suggested that imbalances might manifest as underutilization
military personnel during combat operations suggest using
rather than overload, i.e. too little need for the ability to cope
such constructs as combat mental trauma, combat stress,
with stress [1].
combat mental pathology, post-traumatic stress disorders,
In our opinion, one of the leading modern paradigms of the and others definitions.
problem of stress, which is used by both scientists and
The official website of the US Department of Defense provides
practical psychologists in their work, is the conservation of
the definition of combat stress, also known as battle fatigue,
resource theory proposed by Stephen Hobfoll. According to
which is a common response to the mental and emotional
this theory, stress arises from motivation that encourages
strain that can result from dangerous and traumatic
people to both maintain their current psychological resources
experiences. It is a natural reaction to the wear and tear of the
and seek new opportunities [1]. Its main principle is that
body and mind after extended and demanding operations [44].
individuals strive to obtain, retain, foster, and protect those
Combat stress reaction (CSR) is a term used within the military
things they centrally value. The main postulates of this theory
to describe acute behavioral disorganization seen by
are understanding that stress occurs when: (a) central or key
personnel as a direct result of the trauma of war. CSR is an
resources are threatened with loss, (b) central or key resources
acute reaction that includes a range of behaviors resulting
are lost, or (c) there is a failure to gain central or key resources
from the stress of battle that decrease the combatant's
following significant effort [1].
fighting efficiency. The most common symptoms are fatigue,
Essentially, the conservation of resource theory is a slower reaction times, indecision, disconnection from one's
motivational theory that explains much of human behavior in surroundings, and the inability to prioritize. The combat stress
terms of the evolutionary need to obtain and maintain reaction is generally short-term. The US Army uses the
resources for survival, which is central to the genesis of human term/acronym COSR (Combat Stress Reaction) in official
behavior [42]. Resources are defined as those objects, medical reports. This term can be applied to any stress
personal characteristics, conditions, or energies that are reaction in the military unit environment. Many reactions look
valued by the individual or that serve as a means for the like symptoms of mental illness (such as panic, extreme
attainment of these objects, personal characteristics, anxiety, depression, and hallucinations), but they are only
conditions, or energies. According to the authors, people must transient reactions to the traumatic stress of combat and the
acquire and maintain both strong personal characteristics and cumulative stresses of military operations [45].
social ties. Thus, people must use key resources not only to
Blinov defines combat stress as a reaction of the psyche to a
respond to stress but also to create a certain amount of
threat to life and health in the form of a process of
supportive resources in case of future needs. Moreover, the
experiencing mental states at the stages of adaptation using
acquisition and maintenance of personal, social, and material
the resource potential [9].
resources create in people, families, and organizations the

17
Snedkov makes a distinction between combat stress, combat this is fraught with detrimental biological consequences:
psychic trauma, and combat psychic pathology [46]. Under excessive and prolonged nervous excitement after an injury
combat stress, the author understands “a multilevel process of can increase the likelihood of developing PTSD [49].
adaptive activity of the human body in a combat situation,
accompanied by a tension in the mechanisms of reactive self- EFFECTS OF COMBAT STRESS ON MILITARY PERSONNEL
regulation and the consolidation of specific adaptive
American researchers have proposed a more detailed
psychophysiological changes. Combat mental trauma is a
classification of stressors associated with external and internal
pathological condition of the central nervous system, which is
factors [47]. They determined that combat-related external
formed as a result of combat stress that exceeds the adaptive
stressors included: self-injury; the killing of combatants;
potential of a particular individual and forms the 'patos' of
monitoring the death of people; death of colleagues; injury
combat mental pathology. Combat mental pathology is a
resulting in the loss of a limb. External stressors associated
syndromic and nosologically structured clinical manifestation
with military operations include prolonged exposure to
of combat mental trauma, the occurrence of which is due to
extreme environmental conditions; reduced quality of life and
the failure of compensation and the generalization of the
communication resources for a long time; prolonged
pathogenetic mechanism” [46, pp. 28-29].
separation from important support systems (e.g., family);
The authors of this article define the term “combat stress” as overseeing significant casualties across many missions (for
the process of the influence of combat situation factors on a example, overseeing the deaths of several unit comrades
soldier, accompanied by a decrease in the level of during combat operations). External physical stressors include
psychological safety of personality and the appearance of non- exogenous (heat, cold, moisture, dust; vibration, noise,
specific preclinical psychological manifestations, which explosions); harmful odors (smoke, poison, chemical
together are presented by the concept of “combat compounds); ionizing radiation; infected environment;
psychological trauma of personality” or reach specific physical work; poor visibility (bright light, darkness); difficult
nosological symptoms of mental disorders, united in the terrain; being at height. Physiological stressors that can cause
concept of “combat mental trauma”. Combat stress in military combat stress include sleep deprivation; dehydration;
personnel can manifest itself in the form of negative malnutrition; poor hygiene; muscle and hypoxic fatigue; illness
manifestations of the psychological, physical, or injury; sexual frustration; the use of psychoactive
psychophysiological, and behavioral register. substances (caffeine, alcohol, drugs); obesity; poor physical
condition [47].
According to American mental health experts, combat and
operational stress include all types of psychological and Mental (internal) stressors include cognitive; requirements or
emotional stress that arise as a result of the dangers and expectations, difficult decisions (combat rules); organizational
requirements of performing tasks in warfare and other military dynamics and change; difficult choices or lack of it; work that
operations [47]. The development of combat stress in military goes beyond their own competence; preliminary failures.
personnel, according to the authors, is directly influenced by: Emotional (internal) stressors are new to the unit; isolation,
the intensity and duration of a traumatic event or situation; loneliness; fear and threats that cause anxiety (death, injury,
the level of psychological resilience and endurance of the failure, or loss); losses that cause grief (mourning); indignation,
individual; self-efficacy of a person (the ability to take certain aggression, and frustrations, causing anger and a feeling of
actions to achieve a specific goal); collective effectiveness sadness; conflict (ambiguous) motives; inactivity that causes a
(general belief in the collective power to achieve the desired feeling of sadness; religious confrontation or temptation to
results); neurobiological factors (heredity, differences in the lose faith; interpersonal conflicts (in a unit or with comrades);
activity of the sympathetic nervous system, features of cortisol family problems, nostalgia for home; victimization, sexual
release in response to psychological stress, serotonin claims; observation of the battle, dead bodies; murder [47].
metabolism, etc.).
During deployment, military personnel is influenced by
The effects of combat stress are mediated by a complex combat stressors (seeing dead human bodies, being attacked
interaction between changing factors specific to each person or ambushed, knowing someone who was injured or killed,
and situation, as well as the dynamic interaction between and handling dead bodies) as well as operational stressors:
them. Thus, managed moderately mild stressors can have a long deployments, uncertain redeployment date, separation
“hardening” or stress-modifying effect, when the body from families and lack of privacy [49,50,51]. Potentially
becomes less reactive to future stressors. Researchers have morally compromising war circumstances, as noted by
found that attention and arousal are essential for survival Wortmann et al., could involve prescribed roles (e.g. maiming
[30,48]. However, when they go beyond the maximum range, and killing), proscribed behaviors (e.g. the use of excessive

18
force or cruelty), bearing witness to the aftermath of violence The use of TRiM may assist in increasing the psychological
or terror (e.g. handling or uncovering human remains) or being resilience of military personnel through the facilitation of
a victim of others’ failures to uphold a moral code [52]. As a social support; this may have particular utility during
consequence, many service members suffer moral injury, operational deployments [57].
characterized by guilt, shame, anger, social withdrawal,
The Israel Defense Forces developed YaHaLOM training to
feelings of worthlessness, self-blame, and spiritual distress
teach service members how to manage ASRs in team members
[33,52].
[58] and then adapted into ICOVER by the U.S. Army. YaHaLOM
Effects of combat stress can also cause psychological trauma is a novel, rapid, peer-based intervention specifically designed
in military personnel, which can manifest itself both during the for use amid a high-stress event.
performance of combat missions and in the long-term period
The analysis of scientific sources made it possible to determine
after their completion [7,30]. However, according to Born and
that the most effective system for the prevention and control
Zamorski, deployment-related factors and exposure to
of combat stress among military personnel exists in the US
potentially traumatic deployment experiences have the
Army. Let’s consider this system in more detail. There is a
strongest and most consistent association with post-
specific terminological apparatus for defining terms related to
deployment mental health problems [53]. They may have
combat stress that is used by mental health professionals in
short-term transient signs of the pre-nosological registry or
the US military. They are set out in various legal documents
more complex and severe somatic, psychiatric disorders,
that regulate the professional activities of these specialists:
which should be well documented [27].
COSC programs are set out in Field Manual 4-02.51 “Combat
Recovery after exposure to combat stress can be facilitated by: and Operational Stress Control” and 6-22.5 “Combat and
a person’s desire to open up and social support; the feeling Operational Stress Control Manual for Leaders and Soldiers”
that the social environment will accept the person’s reactions [45,59].
with understanding and will encourage his openness;
Thus, the control of combat and operational stress in the US
perception of the veteran as a hero or victim, but not as a
Army is defined as the developed programs and activities of
victim; a sense of connection with God, a higher power, or a
military leaders aimed at preventing, identifying, and
philosophical teaching; trauma-focused treatment to rethink
managing dangerous behavior and combat stress reactions
negative reactions, clear intrusive memories, and help
that may occur in military personnel [59]. The objectives of the
distinguish past from present threats [47].
COSC program are optimization of task performance;
Post-traumatic social support and relatively rare post- maintaining combat power; preventing the harmful effects of
traumatic negative events may also serve as protective factors combat stress reactions on the physical, psychological,
that will aid recovery from trauma [54]. intellectual, and social health of military personnel or
minimizing these effects; prompt return of soldiers to duty
COMBAT AND OPERATIONAL STRESS CONTROL (COSC) [60].
PROGRAMS IN MILITARY PERSONNEL
Also, one of the main tasks of the COSC is to increase unit
In our opinion, programs for the prevention and control of cohesion and combat capability in a highly stressful military
combat stress among military personnel are more effectively environment and to maximize post-traumatic growth [48].
implemented in the Armed Forces of the United States, Great COSC includes such activities as in-depth medical examination
Britain, and Israel; other countries are developing similar (screening) and psychodiagnostic of recruits; long-term
activities based on these programs. observation of the passage of service, especially before,
during, and after combat deployment; ongoing monitoring and
Trauma Risk Management (TRiM) is a peer-support program
consultation of mental health personnel from the US home
that aims to promote help-seeking military personnel in the
base to the combat deployment area [61].
aftermath of traumatic events, developed by the UK Royal
Navy [55]. This program reflects a peer-led, occupational In the past, when US military personnel participated in
mental health support process that aims to identify and assist operations in Korea and Vietnam, the consequences of the
U.K. military personnel with persistent mental ill health related negative impact of combat stress led to almost half of the
to potentially traumatic events [56]. TRiM seeks to modify psychogenic losses on the battlefield, depending on the
attitudes about PTSD, stress, and help-seeking and trains complexity of the conditions [47]. Although the level of acute
military personnel to identify at-risk individuals and refer them (combat) stress reactions remained high in the wars of the 21st
for early intervention. century, losses were significantly reduced. This was due to the
introduction of COSC programs into the functioning of military

19
units. According to American mental health professionals, in standard psychological debriefing after critical incidents
modern wars, military leaders can expect 95% of military (military deaths and large numbers of wounded). Instead,
personnel with ASRs should return to combat missions [47]. these specialists monitored the mental state of military
COSC is effective when it comes not only to military personnel personnel and their commanders during mandatory post-
but also to their training and support systems, including combat checkups and interviews [35].
meaningful interpersonal relationships, families, and external
To organize psychological support for military personnel,
resources. COSC aims to identify members of the armed forces
specialized mental health units were deployed near the line of
and their families, as well as US Army civilians who may need
combat, the main purpose of which was the early
assistance due to challenges associated with participating in
identification, assistance, and early return to normal activities
combat deployments, and to ensure that they are better
of such military personnel in the units [62]. All countries have
prepared, stable, and reliable at all stages accomplishment of
deployed mental health support teams made up of a variety of
combat missions. If we consider the personal level of a soldier,
professionals, including psychiatrists, psychologists, social
then the goal of COSC is to improve the readiness of each
workers, nurses, and priests [63]. There was no consensus on
soldier and the unit as a whole to perform a combat mission.
the distribution of mental health disciplines in the war zone.
This can be achieved by: improving adaptive stress responses
and preventing unproductive coping strategies; helping All countries, except the United States, organized
military personnel control combat stress responses; helping psychological decompression for personnel in temporary
soldiers with behavioral problems [6]. deployment elsewhere (outside the combat zone, but in areas
of temporary deployment of units) within a few days after the
Overall, the US Army’s COSC is one of 10 medical systems
completion of combat deployment. Its main goal was to
active during pre-combat, on the battlefield, and at the end of
recognize faces with signs of combat stress reactions, to
a mission. Five professional disciplines in mental health and
provide them with assistance, psychological support, and
two additional ones are directed to the implementation of
preparation for sending them to permanent deployment
COSC. Professional disciplines include social work, clinical
points (home). The US Army conducted intra-garrison
psychology, psychiatry, occupational therapy, and psychiatric
decompression or reintegration training directly in the US [8].
nursing. Additional disciplines include mental health and
But psychological decompression had a fairly comparable
vocational rehabilitation.
infrastructure in the field of psychiatric and psychological care.
An analysis of the COSC programs of different armies of NATO
Common concerns across countries included perceived stigma
partner countries in the field of international security
(unwillingness or fear of military personnel to seek help from
assistance showed that they are similar in terms of
mental health professionals), barriers to mental health care,
organizational principles, main goals, and tasks. However,
and the need to increase awareness and acceptance of mental
these programs differ structurally from the US Army COSC and
health issues among military personnel [64].
have their own characteristics depending on the conditions of
the missions in which the military personnel take part and the In addition to psychological support, modern preventive
performance of combat missions. Such a comparison of COSC psychiatric treatment was included in all COSC programs,
programs was made during a mission in Afghanistan among including a positive approach to strengthening mental
five NATO partner countries: the armed forces of Australia, stability. There has also been an emphasis on building self-
Canada, the UK, the Netherlands, and the USA [8]. This allowed regulatory skills, empowering military personnel, and several
the authors to identify and compare organizational structures other innovations well integrated into the military context
and key practices in providing mental health care and support [63]. An important innovation in the operational mental health
to military personnel, identify issues, and illustrate new support of military personnel was the recognition of the role
developments in this area. of social leadership and the need to increase support from
colleagues.
The main comparative themes of the COSC programs were:
education, prevention, early detection, intervention (care), However, not all researchers are positive about the
and follow-up (support) in the field of mental health. The main introduction of COSC programs to prevent the development of
method of organizing support for the mental health of mental disorders in military personnel that occur during and
servicemen was training (psycho-prophylaxis) and monitoring after combat deployment. Maglione et al. believe that
their mental state. The educational goal was to enhance the although COSC interventions may play a valuable role in
mental stability of individual military personnel while decreasing stress, decreasing absenteeism, and enabling a
providing a range of mental health services. All mental health return to duty, a systematic review of studies that included a
officials from these five countries have waived the need for a control/comparison group found little evidence that COSC is

20
effective in preventing PTSD or decreasing PTSD symptom psychological manifestations, which together are presented by
scores in military personnel [65]. the concept of “combat psychological trauma of personality”
or reach specific nosological symptoms of mental disorders,
CONCLUSIONS united in the concept of “combat mental trauma”.

One of the most important directions in the development of To prevent the occurrence and development of combat stress,
military psychology is the study of the problem of stress. The it is necessary to develop and implement a system for the
conservation of resource theory by S. Hobfoll, in our opinion, prevention and control of combat stress in military personnel.
most fully and reasonably explains the genesis of combat Such a program should contain psychological work activities
stress that occurs in military personnel during activities in carried out at three stages: preparatory (before performing
extreme conditions. The main postulate of this theory is that combat missions), the stage of direct performance of tasks in
stress occurs when a person’s central or key resources (health, the combat zone, and the final stage (after completing tasks
well-being, family, self-esteem, and a sense of purpose and upon returning to permanent deployment points).
meaning in life) are threatened with loss, lost, or there is a
failure to gain key resources following significant effort. At its Conflicts of interest and sources of funding
core, the conservation of resource theory is a motivational The authors declare no conflict of interest. No financial support was received
theory that explains much of human behavior in terms of the from any governmental institution, economic or non-governmental organization.
evolutionary need to obtain and conserve resources in order
Authors’ contribution
to survive.
Conceptualization and project management, I.P.; research, YaM., O.K and S.V.;
It was revealed that during the fighting, almost all servicemen methodology, V.V.; formal analysis, N.V.; software, L.B.; writing – original draft
preparation, V.K. and S.M. All authors read and agreed to the published version
experience combat stress. Combat stress is the process of the of the manuscript.
influence of combat situation factors on a soldier,
accompanied by a decrease in the level of psychological safety Ethics approval and consent to participate
All procedures followed were in accordance with the ethical standards of the
of personality and the appearance of non-specific preclinical
Helsinki Declaration of 1975, as revised in 2000.

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 https://doi.org/10.55453/rjmm.2024.127.1.4
The article was received on June 18, 2023, and accepted for publishing on September 2, 2023.
ORIGINAL ARTICLE

A Survey on Mental Health Status in West of Iran: A Spatial Analysis

Ehsan Nazari1, Hojjat Sayyadi2, Fathola Mohamadian3, Sehat Aibod4, Ali Sahebi5, Maryam Kheiry6, Yousef Veisani7
1 Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, IR Iran; [email protected]
2 Non-Communicable Diseases Research Center, Ilam University of Medical Sciences, Ilam, IR Iran; [email protected]
3 Department of Psychology, Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, IR Iran; [email protected]

4 Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, IR Iran; [email protected]

5 Non-Communicable Diseases Research Center, Ilam University of Medical Sciences, Ilam, IR Iran; [email protected]

6 Non-Communicable Diseases Research Center, Ilam University of Medical Sciences, Ilam, IR Iran; [email protected]

7 Non-Communicable Diseases Research Center, Ilam University of Medical Sciences, Ilam, IR Iran; [email protected]

Correspondence: Yousef Veisani, [email protected]

Abstract: Mental disorders clearly are among the major challenges of global health causing many concerns for health systems,
health experts, and health policy makers. The present study was conducted to evaluate the mental health program in
comprehensive health centers and health houses under the coverage of the Ilam University of Medical Sciences in the West of
Iran. The present study was conducted based on the reports obtained from the mental health program in 2019. The data were
recorded into registration and evaluation forms of mental disorders with the codes 102-19-03 and 102-19-01 and then entered
into the Excel software. The prevalence per 100 and 100,000 people, as well as their 95% confidence intervals, were calculated
using Formula 1 ROUND (Number of cases*100000/population) and Formula 2 ROUND (Prevalence ±1.96*SQRT (Prevalence *(1-
Prevalence)/population). The results showed that the prevalence of depression was 19,100 [95% CI: 18999-19201] 19100), and
the prevalence of anxiety was 304,66 [95% CI: 20348-30584] per 100,000 population. The highest prevalence among mental
disorders was related to depression and anxiety. Considering the high average score of mental health status in people over 65
years old, it is necessary to implement measures and interventions to improve these individuals’ mental conditions and upgrade
their mental health.

Keywords: Spatial analysis; Ilam province; Mental health; Iran

INTRODUCTION Industrialization of countries, the growth of urbanization,

migration to cities, etc. are phenomena that are associated
According to the definition provided by the World Health
with numerous troubles, including psychological and social
Organization (WHO), mental health is "a health status that
problems. For this reason, mental health and mental disorders
turns one’s potential talents into reality, enabling people to
are considered top priorities in today’s world. The high
cope with routine life tensions, accomplish valuable work, and
prevalence of mental disorders and their associated
upgrade their social participation" [1]. Mental health is an
morbidities render them an immediate health priority [4].
important component for evaluating the health status of a
population and can be evaluated using various indicators [2]. Excessive attention to physical health problems (such as
In other words, the concept of mental health falls under the infectious and contagious diseases) has caused mental health
general concept of health and refers to all the methods and to receive less priority in many countries around the world,
measures used to prevent people from developing mental including its social and spiritual aspects, which have been
disorders, as well as for the treatment and rehabilitation of overlooked in most cases [5]. Statistics on the global burden of
affected individuals. Psychologists believe that mental health mental illnesses highlight the need to pay attention to these
can be affected by individual characteristics, mental and aspects more than ever. In parallel with the estimation of the
environmental burdens, economic, social, and familial status, WHO, Harvard University and the World Bank declared that
failure to achieve life goals, and lack of motivation [3]. mental disorders were responsible for about 13% of the total

25
burden of diseases in 2006, which was predicted to reach 15% Darrehshahr (Figure 1).
by 2020. The rate of morbidities caused by these disorders has
been reported beyond 33% [6]. In Iran, mental health Figure 1: The geographical location of Ilam province
disorders account for 14.5% of the total burden of diseases,
and after traffic accidents, they share the second rank with
cardiovascular diseases. In women, depression claims the first
place of disease burden, while in men, addiction is considered
the third cause of disease burden[7]. According to studies in
Iran on individuals older than 15 years old, the prevalence of
mental disorders has been 25.9% in women and 14.9% in men,
and it was reported that overall, 21% of people suffered from
some sort of mental problems. Some studies have assessed
the prevalence of mental disorders in Ilam province{8]. In a
population-based study by Visani et al. [9], the prevalence of
DSM-IV mental disorders in both genders was investigated in
the urban areas of Ilam province. Out of 763 participants aged This study was conducted to assess the mental health program
15 years and older in the recent study, 25.8% showed implemented in the comprehensive health centers and health
symptoms of mental distress, and the prevalence of mental houses affiliated with the Ilam University of Medical Sciences
disorders was reported to be 20.9% in men and 29.8% in in 2019. The study was approved by the institutional ethics
women. Also, the prevalence of anxiety, major depressive committee under the code IR.MEDILAM.REC.1399.266. The
disorder (MDD), and obsessive-compulsive disorder was data were gathered by reviewing registration and evaluation
higher in women than in men (23.6% vs. 18.2%; 22.7% vs. forms for mental disorders with the codes 102-19-03 and 102-
17.4%; 13.9% vs. 10%, respectively). In women, the prevalence 19-01 in all ten cities of Ilam province. Then based on the
of phobia was reported as 10.4%. population of each city in 2021, the prevalence of mental
disorders was calculated in 100 and 100,000 people.
Studying mental health status can provide managers and
decision-makers of organizations with valuable information for Analytic Method
planning educational, therapeutic, and preventive measures
After collection, the data of each city were entered into
to reduce the incidence of these diseases in society. Such
Microsoft Excel software, and formulas 1 and 2 were used to
information can be obtained by monitoring the mental health
calculate the prevalence of mental disorders (with 95% CIs) in
status of people in different societies [5].
100 and 100,000 people.
Assessment and monitoring of mental disorders in the country
Formula 1: ROUND (Number of cases*100000/population)
and in Ilam province can help better understand the condition
of mental health and public health in society, which is an Formula 2: ROUND Prevalence ±1.96*SQRT (Prevalence *(1-
important and influential factor affecting social productivity Prevalence)/population)
and wealth creation. Therefore, researchers here aimed to
Also, to determine the geographical distribution of mental
investigate the mental health status of the urban population
disorders in the cities of Ilam province, the commands of
of Ilam using the data recorded in the registration and
spatial analysis in the STATA 11 software (Stata Corp. LLC
assessment forms designed for mental disorders.
College Station, Texas, USA) were used.
Furthermore, we evaluated the mental health program
performed in comprehensive health centers and health houses
RESULTS
covered by the Ilam University of Medical Sciences in the West
of Iran. The results showed that in Ilam province, the prevalence of
depression was 19100 (95% CI: 18999-19201), and the
MATERIALS AND METHODS prevalence of anxiety was 30466 (95% CI: 20348-30584) per
100,000 people. According to the results, the highest
The present cross-sectional study was conducted on the basis
prevalence among mental disorders was related to depression
of the reports derived from the mental health program in Ilam
and anxiety.
province in 2020. According to the statistics announced in
2021, Ilam province harbors a population of over 630,000 The highest rate of depression belonged to Ilam (20300, 95%
people living in ten cities: Ilam, Ivan, Chardavl, Sirvan, CI: 20137-20463) and Malekshahi (21836, 95% I: 21297-22375)
Malekshahi, Mehran, Abdanan, Dehloran, Badreh, and cities, while the lowest rate of depression was reported in

26
Sirvan (16292, 95% CI: 15691-16897) and Badreh (17299, 95% 22228-22970), and Ilam (21200, 95% CI: 210135-21365). On
CI: 16706-17892). the other hand, the cities of Sirvan (16769, 95% CI: 16184-
17404), Chardavl (16499, 95% CI: 16228-16770), and
Also, the highest rates of anxiety were recorded in the cities of
Darrehshahr (19099, 95% CI: 17790-18408) had the lowest
Abdanan (22298, 95% CI: 21922-22674), Ivan (22559, 95% CI:
rate of anxiety (Table 1).

Table 1: The prevalence of depression and anxiety in the population of Ilam province per 100,000 people in separate cities
Major Depressive Disorder Anxiety Disorder
Prevalence Prevalence
Location Population
Number of Rate per 100,000 Number of Rate per 100,000
cases (CI 95%) cases (CI 95%)
Ilam 235144 47734 21200(210135-21365) 49850 20300(20137-20463)
Abdanan 46977 9630 22298(21922-22674) 10475 20499(20134-20463)
Ivan 48833 10236 22559(22228-22970) 11036 20961(20600-21322)
Mehran 27506 5281 22402(21909-22895) 6162 19199(18734-19664)
Badreh 15614 2701 17299(16706-17892) 2701 17299(16706-17892)
Dehloran 66339 13135 18900(18602-19198) 12538 19800(19497-20103)
Darrehshahr 59551 10838 18099(17790-18408) 10778 18200(17890-18510)
Shirvan 14404 2347 16796(16184-17404) 2419 1294(15691-16897)
Chardavl 72167 12412 16499(16228-16770) 11907 17199(16924-17474)
Malekshahi 22587 4932 17196(16704-17668) 3884 21836(21297-22375)
Total 580148 110808 30466(20348-30584) 176750 19100(18999-19201)

Regarding age distribution, the results showed that the highest Regarding the gender distribution of mental disorders, it was
prevalence of depression (29%), anxiety (35.5%), and noticed that depression (20.3% vs. 22.7%), mania (2.6% vs.
psychotic disorder (22.6%) was observed in people over 65 4.7%), anxiety (23.6% vs. 32.18%), obsessive-compulsive
years of age. The psychological disorders of mania (6.3%) and disorder (10% vs. 13.79%), phobia (10.4% vs. 5%), and
obsessive-compulsive disorder (13.3%) were more commonly psychotic disorder (6.17% vs. 2.4%) were more frequent in
observed in the age group of 15-24 years compared to other women than in men (Table 2).
age groups.

Table 2: The prevalence of mental disorders in Ilam province in various age groups and genders
Depression Mania Anxiety OCD* Phobia Psychotic
Age
Prevalence Prevalence Prevalence Prevalence Prevalence Prevalence
groups/gender
(CI95%) (CI95%) (CI95%) (CI95%) (CI95%) (CI95%)
15-24 years 14.0 (7.08-15.1) 6.3 (5.9-7.3) 14.7 (12.1-16.8) 13.3 (9.04-15.15) 8.4 (6.9-11.1) 0.7 (0.01-5.9)
25-44 years 20.6 (18.2-22.3) 4.0 (2.6-9.1) 21.2 (16.2-18.2) 11.3 (9.13-14.2) 7.5 (6.9-11.1) 4.8 (3.6-6.3)
55-64 years 22.7 (20.2-24.3) 2.3 (1.4-2.9) 23.6 (20.3-25.2) 13.4 (8.1-16.1) 8.3 (7.9-11.3) 3.7 (1.2-5.7)
>65 years 23.6 (20.3-25.2) 0.4 (0.1-1.1) 35.5 (32.3-37.8) 9.7 (7.1-11.2) 9.7 (7.1-12.2) 22.6 (20.2-27.6)
Male 17.4 (15.1-19.6) 2.6 (1.3-8.7) 18.2 (15.2-21.1) 10.0 (8.1-12.4) 5.0 (3.7-8.2) 2.4 (1.4-4.1)
*OCD – Obsessive-compulsive disorder

The results of the spatial analysis regarding the geographical province, showing the highest prevalence in Ivan City. Also,
distribution of mental disorders in Ilam province showed that panic disorder was more prevalent in southern cities of the
depression, anxiety, and mania were more commonly province (Abdanan and Dehloran) than in other cities (Figure
observed in the northern compared to southern regions of the 2).

27
 Figure 2: The results of spatial analysis. Geographical distribution of the most common mental disorders in Ilam province

DISCUSSION so the highest prevalence (49.9%) was related to people over

the age of 65 years. Among the reasons for the higher
The results of the present study showed that the highest
prevalence of mental health disorders in older people can be
prevalence of depression, anxiety, and psychotic disorders was
retirement, menopause, loneliness-associated anxiety, and
observed in people over 65 years old. In this study, age showed
biological alterations. The results of these studies are generally
a direct and significant correlation with having unsatisfactory
consistent with our findings; nevertheless, some discrepancies
mental health, indicating the importance of advancing age in
can be explained by differences in the assessment tools
the development of mental health problems such as
employed and the age spectra of the studied populations.
depression, anxiety, and psychotic disorders. In other words,
the incidence of mental health disorders increased with age, The results of this study showed that the highest prevalence of
contradicting the findings of Heidari et al. [10] and Jafari et al. panic disorder and obsessive-compulsive disorder was related
[11]. In recent studies, higher age was reported to be to the age group of 15-24 years. Mental disorders in teenagers
significantly associated with more favorable mental health. and young adults exacerbate the predicted future burden of
Other studies; however, have reported a significant diseases and adversely affect numerous life aspects, including
relationship between mental health and advancing age, educational performance, employment, income, personal
including a report by Visani et al. [12]. In another study, relationships, and social participation, as well as workforce
Noorbala et al. [13] noted that with increasing age, the [14]. In a study in Brazil conducted on individuals aged 18 years
likelihood of the development of mental disorders increased and older, it was shown that younger people were more

28
vulnerable to mental problems [15]. In another study in Iran, psychological pressure, and unnecessary tensions, which can
Shirzadi et al. [16] declared a higher prevalence of these be achieved with the help of mass media by nurturing a
disorders in people aged 41 years or older compared to 18-40- comfortable atmosphere. Moreover, the establishment of
year-old individuals. psychological counseling clinics can be among low-cost and
beneficial measures to cover a large population, including
Also, the results of the present study revealed a lower
young people, middle-aged, and elderly people, so that they
prevalence of depression and anxiety in women than in men.
can amend and improve their mental health.
In a study, Falahzadeh and Momayezi [17], who investigated
the prevalence of depression, anxiety, and stress in Yazd city
CONCLUSIONS
of Iran, noted that depression, anxiety, and stress were more
prevalent in women than in men, and this difference was The results of this study affirmed a relatively high prevalence
statistically significant for anxiety (P=0.01) and stress (P=0.02), of suspected mental health problems among people over 65
which was not consistent with our observation. We also years of age, which is an alarming call,
noticed a higher prevalence of obsessive-compulsive
requiring authorities and researchers to pay more attention to
disorders, phobia, and psychotic disorders in women
this issue and to identify and modify the factors affecting the
compared to men, which was in agreement with the reports of
mental health of these people. A unique observation in this
Pendrez et al. [18], Kesler et al. [19], and Chang et al. [20]. The
study was the lower prevalence of anxiety and depression in
higher prevalence of mental disorders in women compared to
women than in men. Also, we noticed that panic disorder and
men can be attributed to biological factors, gender-related
obsessive-compulsive disorder were most prevalent in the age
differences, environmental and occupational stress, as well as
group of 15-24 years. A reduction in the prevalence of mental
limited sources of satisfaction and social participation of
disorders can enhance social liveliness. In this regard,
females.
increasing people’s awareness of ways to reduce mental
Although in the present study, a significant portion of the disorders, expanding psychological counseling centers across
urban population declared that they had unsatisfactory mental the city, the establishment of counseling phone lines, residing
health conditions, this may not exactly match the clinical counselors and psychologists in public places such as mosques,
definition of adverse mental health. Therefore, the results of expansion of parks and enjoyable environments, equipping
such subjective studies should not be regarded as a basis for parks with sports devices, and finally, encouraging people to
judgment about the true condition of the mental health of use these services can help reduce depression and anxiety in
respondents. Nevertheless, one should admit that a ratio of society.
people, especially among women, suffer from some degree of
mental health disorders. In this regard, the key measures that Conflicts of interest and sources of funding
can be taken may be to initially achieve a correct The authors declare no conflict of interest. The source of the funding code is the
understanding of the issue and then to implement code of IR.MEDILAM.REC.1399.266.
comprehensive interventions for monitoring populations as
Authors’ contribution
large as possible, especially among vulnerable groups. Conceptualization, E.N. and Y.V.; methodology, E.N.; formal analysis, H.S;
Numerous viable strategies are available to maintain and investigation, Y.V.; data curation, F.M. and A.S; writing—original draft
improve public health. For example, unemployment has been preparation, S.A.; and M.Kh.; writing—review and editing, S.A; F.M. and M.Kh.
All authors have read and agreed to the published version of the manuscript.
pointed out as an important factor contributing to the
development of mental health disorders [21]. So, an important Acknowledgments
intervention that governments can employ is to create more This article was the result of a research project approved by the Research Deputy
jobs, especially for youth, and to improve people’s livelihoods of Ilam University of Medical Sciences under the ethics code of
IR.MEDILAM.REC.1399.266. The researchers are obliged to sincerely express their
as much as possible. Also, another effective measure for gratitude to the colleagues in the research deputy of the university and all those
improving mental health is to remove the sources of distress, who assisted us in conducting this study.

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 https://doi.org/10.55453/rjmm.2024.127.1.5
The article was received on June 20, 2023, and accepted for publishing on August 21, 2023.
ORIGINAL ARTICLE

Investigating the Predictive Power of the Theory of Planned Behavior on the Behavioral
Intention of Healthy Eating in Adolescents

Elnaz Ashrafi1, Farbod E.F. Azar2, Morteza Mansourian3, Fereshteh Osmani4

1 Department of Health Education and Promotion, School of Public Health, Iran University of Medical Sciences, Tehran, Iran; [email protected]
2 Health Promotion Research Center, Iran University of Medical Sciences, Tehran, Iran; [email protected]
3 Health Promotion Research Center, Iran University of Medical Sciences, Tehran, Iran; mansourian55@ gmail.com

4 Dental Clinical Research Development Unit, Birjand University of Medical Sciences, Birjand, Iran; [email protected]

Correspondence: Farbod Ebadi Fard Azar, [email protected]

Abstract: Background: Adolescence is a complex and sensitive period, and learning nutritional concepts during this period is very
important. The purpose of the present study is to determine the predictive power of the theory of planned behavior on the
behavioral intention of healthy eating in adolescents. Methods: 400 first-grade female students of Bandar Anzali participated in
this descriptive-correlational study. Among the first secondary schools of this city, two schools were randomly selected and
sampled by census method. The data collection tool was the healthy eating behavior questionnaire based on the theory of
planned behavior, which included two sections of demographic information and the constructs of the theory of planned behavior,
which were checked and confirmed with the content validity ratio, content validity index, and alpha coefficient. Data were
analyzed using SPSS version 22 software. Results: Linear regression analysis showed that a total of 34% of the variance of healthy
eating behavior intention is predicted by the constructs of perceived behavioral control and attitude. Conclusion: Considering the
high predictive power of the theory of planned behavior in the field of healthy eating behavior, educational interventions based
on it and centered on predictive structures are suggested.

Keywords: theory of planned behavior, healthy eating, adolescents

INTRODUCTION more decision-making power and independence than children

and are heavily influenced by friends, people around them, the
Non-communicable diseases (such as cardiovascular diseases,
environment, and various advertisements, and they turn to
diabetes, cancer, high blood pressure, obesity, etc.) are the
foods with an attractive and seductive appearance but lacking
main cause of death worldwide [1]. Due to the increase in the
in nutritional value, many ready-made foods and snacks are
death rate caused by these diseases, especially in developing
among these materials [9]. Most of them do not consume
countries, the World Health Organization (WHO) declared
enough fruits and vegetables, instead, they consume high-fat,
non-communicable diseases among the health priorities in
energy-rich, and nutrient-poor foods [10].
developing countries two decades ago [2]. Iran, as an example
of a middle-income country, accounted for 83.5% of all deaths According to the 2019 GSHS (Global School-based Student
and 78.1% of the total disease burden in 2019 due to non- Health Survey), almost half of the countries reported that 10-
communicable diseases [3-5]. 30% of students aged 13-15 did not eat any fruit, a quarter
reported that 10-30% of students did not eat any vegetables,
The role of nutrition as the main cause of these diseases has
and almost 70% of countries reported that at least half of their
been proven correctly [6]. In this regard, especially, the
students eat junk food on a weekly basis and all countries have
unhealthy eating behavior of teenagers is worrying [7]. Rapid
found that one in five students consumes carbonated drinks at
growth, and changes in body composition, physiology, and
least once a day [11].
endocrine system accelerate nutritional needs and increase
the risk of malnutrition in this group [8]. Adolescents have

31
Among Iranian teenagers, high consumption of junk foods and committee of Iran University of Medical Sciences and the
unhealthy snacks, not eating breakfast, and low consumption necessary coordination with the education organization of
of fruits, vegetables, whole grains, and dairy products have Bandar Anzali city, the principals and officials of the relevant
been commonly reported [12] and this will cause them to schools, and the informed consent of the students. The data
develop chronic diseases in the future, especially girls who are collection tool was the healthy eating behavior questionnaire
considered as the future mothers and their eating behavior based on the theory of planned behavior [21].
and learning nutritional concepts affect their own health and
This questionnaire includes two sections of demographic
that of their children and families [13,14].
information and constructs of the theory of planned behavior.
Modifying eating habits and behaviors during childhood and The first part of this questionnaire included 8 items related to
adolescence can prevent the occurrence of many non- demographic characteristics, including student age, height,
communicable diseases in adulthood [15]. On the other hand, weight, parent’s education, parent's occupation, and
the future of any country depends on how it takes care of its household size. The second part or constructs of the theory of
children and teenagers. If action is taken to meet their health planned behavior consists of 32 items, and the third part, or
needs, the possibility that the adults of that society will have a food behavior part includes 7 items, based on the 5-point
healthy and valuable life pattern in the future will increase Likert scale each item, as (strongly disagree, disagree, no idea,
[16]. On the other hand, the future of any country depends on agree, strongly agree) with a minimum and maximum score of
how it takes care of its children and teenagers. If action is 1 to 5. The second part of the questionnaire includes attitudes
taken to meet their health needs, the possibility that the adults toward behavior with 12 items with an achievable score range
of that society will have a healthy and valuable life pattern in of 12 to 60, 13 items for subjective norm with an achievable
the future will increase [17]. score range of 13 to 65, perceived behavioral control with 7
items with an achievable score range of 7 to 35, behavioral
Studies show that the most effective educational programs are
intention with 6 items with an achievable score range of 6 to
based on theory-based approaches that are rooted in behavior
30. In the present study, due to the limitation of answer
change patterns, and the "theory of planned behavior" is one
options for items in the questionnaire, which were 4-point
of the well-known ones [18]. According to this theory, attitude,
Likert, the questionnaire was re-validated and reliable.
subjective norms, and perceived behavioral control affect the
intention to perform a behavior [19]. A person's attitude is a To assess the validity, content validity was used, so that the
favorable or unfavorable evaluation of behavior formed questionnaire was given to 10 health and nutrition experts,
through past experiences. and its validity was confirmed with a content validity ratio
(CVR) of 0.81 and a content validity index (CVI) of 0.8. To assess
Subjective norms refer to the social pressures perceived by the
the reliability, Cronbach's alpha test method was used. For this
person who agrees or disagrees with the behavior and the
purpose, a questionnaire was given to 20 female high school
media, family, and friends play a role in it. Finally, perceived
students. Cronbach's alpha coefficient was 0.85 for the
behavioral control is a person's belief about how easy or
attitude construct, 0.75 for the subjective norm construct, and
difficult it is to perform a certain behavior [20]. According to
0.71 for the perceived behavioral control construct, 0.76 for
the explanations provided, the present study was conducted
the behavioral intention construct. Data analysis was done by
with the aim of determining the predictive power of the theory
SPSS software version 24.
of planned behavior on the behavioral intention of healthy
eating in adolescents.
RESULTS

MATERIALS AND METHODS In this study, the mean age of students was 14.9 ± 0.78 years.
Their mean height and weight were 159.7 ±10.7 and 54.7± 1.4,
This is a descriptive-correlational study, which was conducted
respectively, and the household size was 4.1 ± 0.8. In terms of
in 2022. The research population was 400 first-grade high
employment, the highest frequency was for fathers (45%) as
school girls in Bandar Anzali. From among the first high school
self-employment and 86% of mothers were housewives. In
girls in this city, two schools were randomly selected and
terms of education, 42% of fathers and 45% of mothers were
sampled by census method. Inclusion criteria included:
at the level of high school and high school diploma, each of
students' willingness to participate in research, lack of a special
which with the highest percentage of frequency. The mean,
diet and not suffering from chronic diseases, and exclusion
standard deviation, and range of obtainable scores for each
criteria were unwillingness to participate and continued
construct of the theory of planned behavior in the studied
cooperation by students.
students can be seen in Table 1.
The study was initiated with the permission of the ethics

32
 Table 1: Mean, standard deviation, and range of obtainable scores constructs of the theory of planned behavior that there is a
for each of the constructs of the theory of planned behavior in the direct and significant correlation between all constructs
studied students (attitude, subjective norm, and perceived behavioral control)
Rang of with the intention of eating behavior (P<0.001). The construct
Variable Mean ± SD‣
attainable score
of perceived behavioral control has the highest correlation
attitude 40 ± 6.21 12-60 with the intention of eating behavior (r=0.302).
subjective norms 38.9 ± 6.44 13-65
The linear regression analysis in Table 3 showed that a total of
perceived behavioral
24.06 ± 6.44 7-35 34% of the variance of the intention of healthy eating behavior
control
behavioral intention 25.47 ± 9.21 6-30 in the studied students is predicted by the constructs of
‣ Standard Deviation perceived behavioral control and attitude, and perceived
behavioral control is the strongest construct related to the
Table 2 shows the results of Pearson correlation between the intention of eating behavior in this study.

Table 2: Correlation between the constructs of the theory of planned behavior

Perceived Behavioral
Variable Attitude Subjective norms
behavioral control intention
attitude 1
subjective norms 0.191 1
perceived behavioral control 0.276 0.145 1
behavioral intention 0.182 0.255 0.302 1

Table 3: Predicting the behavioral intention of healthy eating based on the theory of planned behavior in the studied students
Model B Std. Error Beta sig
(Constant) 5.231 3.424 _ 0.127
attitude 0.157 0.070 0.113 0.024
1
subjective norms 0.119 0.085 0.088 0.163
perceived behavioral control 0.371 0.103 0.230 0.000
a. Dependent Variable: Intention of food behavior; b. R2 = 0.34

DISCUSSION has little information or the resources available to the person

change and when new elements such as eating habits are
The present study was conducted with the aim of determining
added to the situation [28, 29].
the predictive power of the theory of planned behavior on the
behavioral intention of healthy eating in adolescents. The The second construct predicting the intention of healthy
result of the study shows that a total of 34% of the variance of eating behavior in this study is the attitude, which is consistent
healthy eating behavior intention in the studied students is with the results of the study by Mousavi et al. [30] concerning
predicted by the constructs of perceived behavioral control beverage consumption and the study by Gronhoj et al. [22]
and attitude, and perceived behavioral control is the first and regarding the prediction of healthy eating behavior and the
strongest construct related to behavioral intention, which is study by Mamun et al. [31] on the determinants of healthy
consistent with studies predicting healthy eating in Danish eating. Attitude shows an individual’s general feeling about
adolescents [22] and the results of the study by Seo et al in the desirability or undesirability of something, and sometimes
Seoul, which implies a significant relationship between people's attitude during life as well as sufficient awareness and
behavioral intention and perceived behavioral control knowledge, which is a prerequisite for attitude change, leads
construct [23]. It is also consistent with the findings by to the intention of performing the desired behavior in the
Yarmohammadi et al. [24] and Dunn et al. [25] on junk food future [27]. Therefore, the attitude that originates from
consumption based on the theory of planned behavior. feelings and internal factors can affect his eating behavior by
However, it is not consistent with the findings of Ickes et al. increasing his information and experiences concerning
[26] on beverage consumption and the findings of Gholami et nutrition.
al. [27] on fruit and vegetable consumption. Perceived
In this study, the subjective norm is not a predictor of eating
behavioral control may not predict behavior when a person
behavior intention, which is similar to the finding by Ismawati

33
et al. [32] on the application of the theory of planned behavior mentioned.
in the intention of healthy eating in Malaysia and the study of
Brouwer et al. [33] related to healthy eating behavior Conflicts of interest and sources of funding
prediction and finding by Dehdari et al. [34] regarding the The personal interests of the authors were not related to the results of this
consumption of unhealthy foods. However, it is inconsistent research. The authors declare that they have no competing interests. This study
with the findings of Khorasani et al. [35] on unhealthy food did not receive any grant from funding agencies.

consumption and White et al. [36] regarding intention to

Authors’ contribution
consume low-fat food. The reason for this inconsistency can be All authors were responsible for the study. EA, MM, and TD were accountable for
the difference in the gender of the participants, in the study of the study Conceptualization and led the writing of the paper. BI conducted the
Dehdari et al. [34], as in the present study, the target group is Literature review and assisted in writing the paper. MM and OS performed the
Statistical analysis, assisted in interpreting the data, and wrote the paper. OS,
girls, and in the study of Khorasani et al. [35], boys are the FSI, and EA assisted with the interpretation of the results and drafting of
target group. On the other hand, diverse food cultures and programmatic Implications. FB and MM were responsible for data collection and
customs in Iran and other countries of the world can be the coordination of the study. TD co-led the conceptualization, supervised all aspects
of writing the paper, and provided extensive comments on the manuscript. All
reason for the discrepancy of these studies. The diversity and
the authors have read and approved the final manuscript.
complexities of health behaviors in different groups and in
different conditions can lead to the necessity of planning to Acknowledgments
use the appropriate theories and structures to achieve success The cooperation of all the students and heads and officials of the Iran University
of Medical Sciences and Education Organization of Bandar Anzali and the officials
in interventions in health education and health promotion.
of the studied schools is highly appreciated.

CONCLUSIONS Ethics approval and consent to participate

This article is taken from the approved research project of Iran University of
Perceived behavioral control and attitude are among the Medical Sciences with ethics code number: 1401.886 IR.IUMS.REC. Informed
factors predicting on the behavioral intention of healthy eating consent was obtained from all individual participants included in the study before
in the studied students. The research limitation in the present conducting.

study was the use of self-reporting, and it is necessary to carry

Consent to publish
out educational interventions based on the "theory of planned All participants consented verbally to the publication of the interview data.
behavior" with emphasis on the two predictive constructs

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 https://doi.org/10.55453/rjmm.2024.127.1.6
The article was received on July 31, 2023, and accepted for publishing on August 23, 2023.
ORIGINAL ARTICLE

A Conceptual Analysis of Post-psychotic Depression

Octavian Vasiliu1, Andrei G. Mangalagiu1, Bogdan M. Petrescu1, Cristian A. Cândea1, Corina Tudor1, Cristina F. Pleșa2,3, Diana
G. Vasiliu4, Cristian Năstase5, Carmen A. Sirbu2,3
1 Department of Psychiatry, “Dr. Carol Davila” University Emergency Central Military Hospital, Bucharest, Romania
2 Department of Neurology, “Dr. Carol Davila” University Emergency Central Military Hospital, Bucharest, Romania
3 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

4 Regina Maria Foundation, Bucharest, Romania

5 Department of Neurosurgery, “Dr. Carol Davila” University Emergency Central Military Hospital, Bucharest, Romania

Correspondence: Octavian Vasiliu, [email protected]

Abstract: The conundrum of post-psychotic depression (PPD) is still present in the psychiatric literature, for more than a century
since it was first described by Mayer-Gross. After a short existence in the DSM-IV and ICD-10, this nosological construct was
excluded from newer versions of the mental disorders classifications. Therefore, an exploratory analysis of the PPD concept was
considered useful both from clinical and theoretical perspectives. There is a high prevalence of depressive symptoms in patients
with schizophrenia spectrum disorders (SSD) and, although not all of them represent cases of PPD, they are considered risk factors
for suicide. The arguments and contra-arguments for/against PPD were reviewed, and the potential pharmacological
interventions for this disorder were analyzed. The explored evidence indicates that PPD is worth further investigation, and in
order to differentiate it from schizoaffective disorder, negative symptoms of SSD, or depressive manifestations within the acute
psychotic episodes, clearly defined criteria should be found. The use of validated scales, like the Calgary Depression Scale for
Schizophrenia and the InterSePT Scale for Suicidal Thinking, is recommended for the initial assessment of depression and suicidal
risk in patients with SSD, but also for their monitoring during the acute and maintenance phases. Besides the administration of
combined, antidepressant and antipsychotic treatment, the use of clozapine, and the recommendation to initiate treatment for
SSD with atypical antipsychotics whenever possible, there is a dearth of studies exploring specific interventions for PPD. Future
studies are expected to address the validity of the nosological construct of PPD and the most adequate therapeutic and
prophylactic interventions in patients with SSD.

Keywords: post-psychotic depression, schizophrenia spectrum disorders, atypical antipsychotics, clozapine, typical anti-
psychotics, antidepressants

INTRODUCTION remission of acute psychotic episodes [5]. PPD was described

by several authors as “retarded depression, with strong
Depression that may appear in the context of schizophrenia is
neurasthenic and schizoid components” emerging after the
considered a complex and heterogeneous group of disorders
patient is discharged from the hospital, and often ignored by
[1,2]. Mayer-Gross was the first author who described in 1920
mental health specialists [6]. Depressive manifestations in
the reaction to a psychotic experience that manifests itself as
patients with SSD have been conceptualized as a psychological
a clinical version of depression [3]. He considered “despair” as
reaction to acute psychosis, as previously mentioned, but also
the main clinical characteristic of this depression that follows
as a comorbidity of two distinct pathologies or a proof for the
a full-blown psychotic episode, and considered this
existence of a continuum between schizophrenia and mood
manifestation to be determined by the patient’s increased
disorders [2]. According to psychoanalysts, PPD is a reaction to
awareness about the severity of his/her illness [3,4]. A few
psychosis, which appears after the remission of the psychotic
decades later, Semrad also explored the psychodynamic
episode, more specifically, after the Ego regained a significant
mechanisms for post-psychotic depression (PPD), emphasizing
proportion of its strengths [7,8].
the denial, projection, and distortion of reality after the

36
Some authors, however, reported, based on the analysis of the untreated psychosis, the presence of an FEP, and a higher
temporal relationship between the onset of depressive and number of stressful life events were associated with a higher
psychotic symptoms in 27 patients, that the first reports on risk of PPD [14]. Depression was reported by patients with FEP
mood manifestations were frequently at the same time same as being linked to the psychotic experience and to the process
as the onset of psychosis [9]. Therefore, PPD is a controversial of recovering from this experience [16]. Feelings of shame,
concept, as no specific pattern for its onset could be detected, doubt, and embarrassment, but also loss and social isolation,
leading to the assumption that depressive manifestations may were associated with the presence of the psychotic experience
be only associated with acute psychotic manifestations. [16]. Also, the onset of PPD has been correlated to the
existence of positive symptoms during acute schizophrenia,
However, a series of studies focused on PPD have tried to
especially delusions and hallucinations [17]. A study that
delineate the risk factors, clinical features, and prognosis of
enrolled 44 patients (aged 10-40 years) with schizophrenia, all
this nosological entity, as a distinctive pathology from
of them during their first six months of the illness, explored the
depressive symptoms belonging to acute schizophrenia, mood
risk of developing PPD one year after discharge from the
episodes within a schizoaffective disorder, or adverse events
hospital [18]. Four patients were diagnosed with depression in
of the antipsychotics or other drugs. For example, a
this interval, according to a Hamilton Depression Rating Scale
comparison of patients with schizophrenia presenting or not
(HAMD) score ≥17 [18]. Only one case recovered from PPD
with PPD (N=30 participants in each group) showed that
completely during the follow-up [18]. All patients in this trial
belonging to elementary (or nuclear) families, longer duration
were undergoing phenothiazine treatment throughout the
of psychotic phase, more frequent hospitalizations, and more
monitoring period [18].
sadness and anxiety-somatization during the acute phase of
the disease were associated with PPD [10]. A past history of In a longitudinal study, 17 patients with schizophrenia were
depression was also more frequently reported in the study monitored for 6 months, using the 18-item Profile for Rating
group vs. controls [10]. Age of onset, sadness during the acute Depressive and Schizophrenic Behavior (PRDSB) [19]. After
psychosis phase, premorbid adjustment, social support, and recovering from acute psychosis, only 2 participants
life events were significant determinants of severity for PPD, developed major depressive syndrome [19]. However, over
according to the multiple regression analysis [10]. 40% of these patients were interviewed only by telephone
after their discharge, so a potential bias regarding the
A cohort study with a 10-year follow-up compared the
sensitivity of the assessment method can not be excluded [19].
evolution of 29 patients with schizophrenia and PPD vs. only
Also, the ethnic homogeneity of the study group could be
schizophrenia [11]. Patients with PPD presented at an older
construed as another potential bias that limits the
age with the onset of schizophrenia and more auditory
generalizability of the results.
hallucinations; also, they were admitted more often, but their
hospitalizations were of shorter duration [11]. A longitudinal, observational study (N=105 patients with
schizophrenia) reported during 12 months of monitoring that
A study that explored the main clinical differences between
depression accompanied acute psychosis in 70% of cases, and
primary depression (N1= 98 patients) and PPD (N2= 71
remitted together with psychosis, while PPD appeared in 36%
patients) concluded that depressed mood, reduced energy,
of these patients, without a concomitant increase in psychotic
and pathological guilt were more frequently detected in
symptoms [20].
patients with primary depression, while sleep disturbance and
ideas of reference with a theme of guilt were more Focusing the analysis of the PPD concept on the most
consistently associated with PPD [1]. renowned classifications of mental disorders, this pathology
was mentioned for the first time in the Diagnostic and
The duration of PPD was estimated by different authors as
Statistical Manual of Mental Disorders, 4th edition (DSM-IV),
varying between several days to several months [12], or, more
published in 1994 [21]. PPD, according to the cited source,
specifically, between 2 and 26 weeks [8].
involves the presence of “a Major Depressive Episode that is
Depressive symptoms during a psychotic episode may be as superimposed on and occurs only during the residual phase of
frequent as 50%, and they may correlate with the frequency of schizophrenia” [21]. The definition of PPD required in the
relapses, defined by re-admission rate and total length of DSM-IV the presence of depressed mood, as a core symptom,
inpatient treatment [13]. By comparison, the prevalence of and excluded the direct consequences of drug abuse,
PPD reported in the literature was around 30-36% [14,15]. medication use, or a general medical condition [21]. However,
Higher rates of PPD were reported in patients with a first in the fifth edition of the DSM, published in 2013, this
episode of psychosis (FEP), up to 50% [3,15]. Older age, a nosological entity no longer appears [22].
higher familial load of psychoses, a longer duration of

37
The tenth edition of the International Classification of status [23]. Newer versions of ICD-10 placed PPD in the
Diseases, edited by the World Health Organisation (ICD-10) in category of “other specified depressive episodes” [24]. The
1993, grouped PPD (named “post-schizophrenic depression”) latest edition of ICD (ICD-11), the first version published in
together with different types of schizophrenia, in the same 2019, did not reference PPD [25].
chapter, coded F20 [23]. The definition of PPD was “a
The convoluted trajectory of the PPD concept from its genesis
depressive episode, which may be prolonged, arising in the
to the present day is rather difficult to explain, but several
aftermath of a schizophrenic illness” [29]. It is important,
important factors contributing to this conundrum represent
according to the ICD-10, that residual schizophrenic symptoms
the main objective of the current review (Figure 1).
still be present, although they cannot dominate the clinical

Figure 1: Rationale for exploring post-psychotic depression

High rate of suicide in patients with SSD

High rate of depressive symptoms during acute phase of psychosis, but

also after the remission of this phase

PPD is a negative prognosis factor

PPD influences quality of life and functional recovery

The need to distinguish PPD from other causes of depressive symptoms

•Schizoaffective disorder
•Comorbid MDD
•Depressive manifestations as part of the 5-dimension model of
schizophrenia
•MDD/BD with psychotic features as a differential diagnosis for SSD
•Depression induced by alcohol or other psychoactive substance
•Depression du to another medical condition

The need to formulate specific good practices/therapeutic guidelines for

PPD

PPD= postpsychotic depression, SSD= schizophrenia spectrum disorders, MDD= major depressive disorder

The rationale for conducting this review derives from several To support this, the data presented suggest that PPD is a
important clinical and theoretical aspects. First, it is essential distinct nosological entity from antipsychotic-induced adverse
to obtain adequate control over depressive symptoms in events, negative symptoms of schizophrenia, depression with
patients with SSD, because of the high rates of suicide psychotic symptoms, or schizoaffective disorders [14,17]. This
reported in this population [26]. PPD seems to be a factor for means that good clinical practices in patients with SSD would
negative prognosis in the long-term for patients with involve differentiating between PPD and other frequently
schizophrenia, especially because of the higher risk for suicide, reported confounding factors.
but also due to its significant impact on the quality of life and
general well-being [17]. Second, the need to delineate THE MULTIFACETED CONSTRUCT OF PPD
clinically PPD from other causes of depression in patients with
Although the history of PPD has been over a century, there is
SSD, in order to find the most adequate therapeutic strategies.
a dearth of good-quality studies exploring this pathology's

38
clinical and epidemiological aspects. However, an analysis of
the main dimensions of the PPD construct can be done, based
on the available evidence (Table 1).

Table 1: Pros and cons in the analysis of the PPD construct

Pros Cons
PPD was associated with any type of antipsychotic treatment, PPD does not exist because it consists of adverse effects of older
therefore it is not an adverse event to the first generation antipsychotics
antipsychotics
There are longitudinal studies that confirm the persistence of The construct should not be treated as a distinct entity, it only
depressive symptoms after the remission of acute psychosis and accompanies acute schizophrenia
cases where depression followed a period of psychosis remission
Negative symptoms and depression do not overlap to the point they Negative symptoms cover the presence of depression, therefore
are indistinguishable depression may be observed only after the remission of those
symptoms
There are specific scales for measuring depression in patients with PPD can not have its own diagnosis criteria and its severity can not
SSD, as well as their suicide risk be determined, due to the fact that it is secondary to other
symptoms

To begin with the presentation of the reasons why PPD is not schizophrenia, depression is a core clinical component,
yet a fully recognized diagnosis, it must be specified that PPD together with the positive, negative, agitation-excitement, and
was correlated by different authors with the effects of first- disorganization symptoms [36]. However, as mentioned in the
generation antipsychotics, and they called this phenomenon introductory chapter, there is no reference to PPD in the latest
“pharmacological depression” [27-29]. In a multicenter study versions of the ICD or DSM [22,25].
(N=211 patients with schizophrenia), depression (quantified
The fourth facet of the PPD controversy is represented by the
with HAMD) was detected in 25% of the cases, all of them
fact that although differentiating between schizophrenia,
treated with fluphenazine (either hydrochloride or decanoate)
schizoaffective disorder, and depressive/bipolar disorder with
[30]. This study also showed that depression was associated
psychotic features is quintessential, in clinical practice it is
with a more chronic psychiatric history and a higher rate of
frequently difficult to make the right diagnosis. Factorial
relapse [30]. Also, older drugs used to treat SSD, such as
analysis using validated instruments for psychosis and mood
chlorpromazine or reserpine, have been associated with
symptoms measurement (e.g., Positive and Negative
lethargy, psychomotor retardation, and anergy, which are
Syndrome Scale – PANSS, Young Mania Rating Scale – YMRS,
acknowledged adverse events of these agents [30].
Montgomery Depression Rating Scale – MADRS, and Calgary
Secondly, the negative symptoms of schizophrenia may cover Depression Scale – CDSS) confirmed the existence of very
the depressive symptoms, making them more difficult to complex structure of the clinical manifestations in patients
detect [14,17]. Anhedonia, defined as a reduced ability to with schizophrenia [37]. Subclinical mood symptoms have
experience pleasant emotions, is considered both a negative been confirmed by this type of analysis, structured within up
symptom in SSD, and a central manifestation in major to 15 factors – e.g., positive, negative, somatic, anxiety,
depressive disorder (MDD) [31-34]. Therefore, it is considered neurocognitive, disorganization and manic, depressive,
“a transdiagnostic symptom”, and its explained by psychomotor agitation, hostility/violence [37]. These results
dysfunctions of the reward and aversion pathways in the support the overlapping model of phenotypes between
central nervous system (CNS) [31]. Furthermore, negative psychotic mood disorders and SSD, and the possibility of
symptoms like alogia and avolition may prevent the detection misdiagnosing a patient with a mood disorder and associated
of depressive symptoms, because they interfere with both the psychotic features as having an SSD [37].
interview and the observation of the patients.
However, each of these confounding factors may be
The third aspect refers to a contradiction: although current addressed. The first argument is precarious because even SSD
diagnostic classifications do not include mood symptoms in patients treated with newer antipsychotics may develop
the core criteria for schizophrenia, these are frequently depressive symptoms and the effect of these pharmacological
considered part of the clinical picture, as additional agents on depressive symptoms is only small to medium [38].
manifestations [35]. According to the five-dimension model of According to a Cochrane review, based on five reports about

39
patients diagnosed with both schizophrenia and depression, (N=119 in-patients with acute schizophrenia) concluded that
there was no significant difference in efficacy (evaluated by CDSS had a higher sensitivity than HAMD in assessing mild or
PANSS scores) between quetiapine and haloperidol, sulpiride severe depression, while the specificity was comparable high
was significantly superior to chlorpromazine (reflected in the for both instruments [45].
severity of depressive symptoms), and clozapine was superior
The InterSePT Scale for Suicidal Thinking (ISST) has 12 items
to the association of another antipsychotic and an
and was created to assess suicidal ideation in SSD patients
antidepressant (moclobemide/mianserin) [39]. A significant
[46]. Two validation studies (N=22 and 980 patients with SSD)
reduction of depressive symptoms in patients with
confirmed that ISST is reliable and valid if used to assess
schizophrenia was reported only if a CDSS score at baseline
ongoing suicidal ideation in patients with SSD [46]. Both ISST
was ≥5, unlike the positive, negative, and general symptoms
and CDSS can be used to provide information necessary in the
(scored with PANSS), in a naturalistic study that enrolled adult
case management of patients with SSD and suicidal risk [47].
patients with ≥2 years of treatment with clozapine (N=23) or
other atypical antipsychotics (N=23) [40]. At the follow-up Based on its properties, CDSS is considered a first-line
visit, patients who received other antipsychotics led o superior instrument to determine the severity of depressive symptoms
results when compared to clozapine on depressive symptoms, in patients with SSD, and a review that compared 6 different
but only when the analysis was limited to those with clinically instruments targeting the same symptoms formulated this
relevant depression [40]. It can easily be deduced that the recommendation [44]. A study that explored the diagnosis of
results of studies exploring the impact of antipsychotics on major depressive episodes in 84 patients with schizophrenia
depressive symptoms in SSD are quite heterogenous, varying found that CDSS was superior to the Beck Depression
from no difference in outcomes between typicals and Inventory (BDI), HAMD, and PANSS-D when evaluating the
atypicals, to superiority of clozapine vs. other antipsychotics Receiver Operating Characteristics (ROC) curves [48].
combined with antidepressants, and to superiority of other
However, the possibility that PPD symptoms may be, in fact,
atypicals to clozapine, but only in certain subpopulations.
the continuation of depressive symptoms with onset in the
The second argument is even more difficult to support because acute psychotic phase, can not be completely excluded [7]. On
authors exploring PPD showed that this syndrome “is usually the other hand, if PPD is detected after a period of psychotic
stable phenomenologically, often lengthy, and may be symptoms remission, then it may be considered part of a new
resistant to all treatment modalities” [6]. Even considering the episode of schizophrenia [7].
last part as an exaggeration determined by the lack of
PPD may be confounded with negative symptoms of SSD, as
adequate therapeutic resources when that statement was
previously mentioned. The discussion about primary and
formulated, there is still enough ground to back up an
secondary negative symptoms is a very complex topic, that
independent syndrome, with pharmacological and clinical
clearly exceeds the objective of this paper. As a general
peculiarities. There are authors that contradict the third
definition, primary negative symptoms are intrinsic to
argument, stating that depression is “a frequent comorbidity
schizophrenia, a specific clinical dimension, while secondary
in the course of schizophrenia” [7], and not just a cluster of
negative symptoms derive from the presence of positive
symptoms intrinsic to SSD.
symptoms, depression, antipsychotics’ pharmacodynamical
The fourth argument can also be easily disqualified because properties, substance use disorders (SUDs), and social
there are validated instruments, currently in clinical use, that withdrawal [49-51]. After the remission of psychotic
allow for the monitoring of depressive symptoms in patients symptoms, the depressive symptoms were still present,
with SSD. CDSS is an instrument created by Addington et al., although their rate decreased from 60% during the acute
first published in 1990, for the purpose of measuring psychotic episode, to 40% after 5 years follow-up [52].
depression in SSD, starting from selected items within HAMD
In conclusion, a correct diagnosis of PPD should include a
and Present State Examination (PSE) [41]. This instrument was
clinical and psychometric evaluation of psychotic and
validated on 50 patients with acute psychosis, and it has 11
depressive symptoms, a thoroughly-conducted screening for
items, with a Cronbach’s alpha of 0.84-0.89 [41,42]. The
comorbidities (organic, toxic, or psychiatric) [53-55], an
validity of CDSS in evaluating mood symptoms in patients with
analysis of the risk factors for the persistence of depressive
SSD was confirmed by subsequent studies and reviews, and
symptoms [56,57], a clear collection of personal medical
this scale was significantly correlated with HAMD and MADRS
history (in order to establish the temporal succession of
[43,44]. CDSS differentiated depressive symptoms from other
psychotic and depressive manifestations), and an accurate
clinical manifestations of SSD and also had good predictive
pharmacological anamnesis.
validity [44]. Another study comparing CDSS and HAMD

40
THERAPEUTIC INTERVENTIONS FOR PPD mesylate was initiated to rule out akinesia; all participants
were either non-psychotic or only residually psychotic at
Adapting the type and dosage of antipsychotic agents in
baseline [62]. The PPD diagnosis was based on current major
patients with SSD was signaled by different authors as a
or minor depression for at least four weeks, and a HAMD score
method to decrease the risk of PPD [2]. Re-evaluation of the
≥12 for at least three consecutive weeks [62]. The depressive
main drugs administered during the acute phase of psychosis
symptoms (according to HAMD and SADS, Schedule for
or the prescription of adjuvant antidepressants or ECT has also
Affective Disorders and Schizophrenia scores) were controlled
been suggested as a case management strategy in PPD [2].
better with imipramine vs. placebo and their global clinical
Psychotherapeutic, social, and institutional support are useful
status (according to the CGI scores) also improved more
options for patients with PPD [2].
consistently in patients receiving the active drug [62]. The
A review (n=20 articles) exploring the results of available psychotic symptoms and tolerability profile did not change
pharmacological and psychosocial treatments of PPD after the significantly between groups [62]. The use of adjunctive
first episode of psychosis did not find support for one imipramine to fluphenazine was further explored by the same
intervention in favor of another [58]. Online psychotherapy team, in a larger and more heterogenous study group [63]. The
and treatment with ω-3 polyunsaturated fatty acids (PUFA) positive effects of the combined treatment were still detected
have been associated with some favorable results [58]. in the total sample, but the significance of the results was
lower [63]. These differences were explained in a post-hoc
Olanzapine (5-15 mg/day) was compared to risperidone (4-8
analysis by the higher level of psychotic symptoms severity,
mg/day) in the treatment of PPD (according to the DSM IV
and by “more refractoriness of depression” due to failed
criteria) in patients with schizophrenia (N=76), and a clinically
previous trials of antidepressants [63].
significant decrease in MADRS scores (-4 points vs. baseline)
was reported after 8 weeks of treatment with either In a continuation trial, four out of five patients previously
antipsychotic [59]. This study used a randomized, double- stabilized on imipramine + fluphenazine decanoate +
blind, parallel-group design. The comparative analysis of the benztropine for PPD relapsed into depression six months after
two interventions did not detect any significant MADRS the tapering of the antidepressant [64]. The control group,
differences at the end-point [59]. A high response rate (≥20% consisting of four patients who did not discontinue
reduction in MADRS scores) was observed during imipramine, did not present depressive relapses [64]. The
antipsychotic treatment [59]. In order to control for possible same research team reported on ten PPD patients with good
confounders of PPD, patients with akinetic symptoms were responses to imipramine who relapsed six months after
excluded from this trial [59]. The same team reported on discontinuation of the antidepressant, that was added to
another randomized, placebo-controlled trial, with 24 patients fluphenazine decanoate and benztropine [65].
diagnosed with schizophrenia or schizoaffective disorder and
A 24-week double-blind trial compared haloperidol (mean
PPD or negative symptoms, who continued their six-month
dose 17.5 mg/day) and thiothixene (mean dose 31.8 mg/day)
adjunctive imipramine to fluphenazine decanoate/
in 46 outpatients with schizophrenia, from their efficacy and
benztropine mesylate treatment or were tapered to placebo +
safety properties [66]. One of the outcomes was the incidence
fluphenazine decanoate/benztropine during one year [60].
of treatment-emergent depression, assessed by the Hamilton
More patients receiving a placebo relapsed into PPD, at a
Depression Rating Scale (HAMD) and Zung Self-Rating
statistically significant level; also, patients who received
Depression Scale (ZSRS) [66]. Haloperidol was superior to
placebo experienced relapses into psychoses [60]. Yet another
thiothixene on the “cognitive disturbance” HAMD factor [66].
trial conducted by the same team showed that double-blind,
Clinically significant symptoms were reported in five patients
controlled discontinuation of imipramine after stabilization
treated with haloperidol and three receiving thiothixene [66].
(N=14 participants with schizophrenia undergoing treatment
The impact on the psychotic symptoms was also more
with fluphenazine + benztropine) led to relapse into PPD in all
important for haloperidol, according to the Brief Psychiatric
patients with placebo vs. only two out of eight in the
Rating Scale (BPRS) scores [66].
antidepressant-receiving group (significant difference,
p=0.009) [61]. In a trial that compared the antidepressant effects of
fluphenazine decanoate (mean dose 32.8 mg fortnightly) and
A controlled trial investigated the effects of imipramine
flupenthixol decanoate (mean dose 36.9 fortnightly)
hydrochloride for PPD for six weeks, in a double-blind manner
administered two-weekly in a group of 48 out- and inpatients
[62]. All patients (N=33) were diagnosed with schizophrenia or
with schizophrenia during 15 weeks [67]. No significant
schizoaffective disorder and received a stable dosage of
differences could be found between groups regarding the
fluphenazine decanoate and one week-trial with benztropine
number and severity of mood impairments and depression

41
[67]. Nineteen patients developed depression, and the symptoms that may reach 90% for at least one such
addition of clomipramine was necessary for five participants, manifestation, and up to 60% for at least one depressive
with a mean duration of four weeks, and an average dose of symptom in FEP [70]. There is a risk of anticholinergic adverse
75 mg/day [67]. The onset of depressive symptoms was events because of the pharmacokinetic interactions between
reported between days 14 and 70 for outpatients and between the two classes of pharmacological agents [68].
days 7 and 77 for inpatients [67]. The onset of depression was
Clozapine is considered a good therapeutic intervention in SSD
unrelated to the antipsychotic dose [67]. The instruments used
associating mood disorders [71]. Risperidone was superior to
to assess depression in this trial were HAMD, von Zeersen’s
haloperidol in decreasing anxiety and depression scores (at 8
self-evaluation scale, and AMP-system [67].
mg/day and 10 mg/day, respectively), and the same atypical
According to a review of 7 studies focused on the use of antipsychotic was more effective than haloperidol and
antidepressants in patients with SSD, tricyclic antidepressants levomepromazine on the Psychotic Anxiety Scale (at 8.6
administered in combination with first-generation mg/day, 9.2 mg/day, and 125 mg/day, respectively) [71].
antipsychotics are a safe choice after the acute psychotic Another review (n=33 studies focused on treatments for SSD
phase is controlled [68]. The risk of exacerbating residual with mood symptoms) concluded that combined treatments
psychotic symptoms is considered minimal by the authors of are as effective as antipsychotics used in monotherapy for
that review [68]. Still, these antidepressants were ineffective acute psychotic exacerbations with depressive manifestations,
against anergy, considered a core symptom of PPD [68]. This is although “some evidence” for superiority was detected in the
a controversial conclusion because “anergy” can be easily case of antipsychotics [72]. For patients developing a major
confounded with several negative signs of schizophrenia (such depressive syndrome after remission of acute psychosis, there
as avolition, apathy, or even anhedonia) [13,49,50,52,69,70]. has been found evidence to support the administration of
The incidence of negative symptoms in patients with SSD is antidepressants, as add-ons to antipsychotics [72]. The results
reported to be high, with more than 57% presenting with at regarding therapeutic response to antidepressants in cases of
least one such symptom, and 41% with at least two negative subsyndromal depression were mixed [72].
symptoms [69]. Other authors report a prevalence of negative

Figure 2: Potential therapeutic interventions for post-psychotic depression

Association of antidepressants to the ongoing antipsychotic

Switching to an atypical antipsychotic, if the patient is on a firt-

generation agent

Switch to clozapine

Add third-generation antipsychotics to clozapine*

Add psychotherapy or neurostimmulation techniques*

Actively search for and treat comorbidities that may influence mood
(substance use disorders, organic diseases, other psychiatric disorders)

*= extrapolated recommendations from studies with other populations than patients with post-psychotic depression; not yet enough evidence to support their use

Newer antidepressants have been launched in clinical use, but depressive symptoms in this population is quite high [52,78].
their efficacy profile in patients with PPD still remains Other interventions, besides antidepressants and atypical
unexplored [73-77]. Also, older antidepressants may be of antipsychotics, are waiting to be investigated in clinical trials
interest for this topic, if added to atypical antipsychotics, for depressive symptoms or major depressive episodes
because, as previously reported, the rate of residual associated with SSD [79-81]. Adding third-generation

42
antipsychotics to clozapine, in cases of ultra-resistance to conditions that may present themselves with depressive
treatment SSD cases, would also have to be considered a symptoms. The data about efficient interventions for PPD
viable option for controlling depressive and negative derives from older studies, therefore new trials exploring new
symptoms [82,83]. Exploring organic, toxic, and psychiatric risk generations of antidepressants are needed for this population.
factors for treatment resistance is important when analyzing Based on the reviewed data, there are elements referring to
the most adequate treatment plan for patients with risk factors, clinical characteristics, epidemiology, and even
depression, PPD included [84-85]. treatment for PPD, but they need to be validated by
prospective, good-quality trials.
CONCLUSIONS

The controversy surrounding the diagnosis of PPD is still under Conflicts of interest and sources of funding

scrutiny, because (1) SSDs associate a high rate of suicide, even None to declare.

after the introduction of new generation antipsychotics, (2)

Authors’ contribution
there is a significant impact of depression on the quality of life OV conceived the idea of the review. OV, AGM, BMP, CAC, CT and CFP designed
and functional recovery in SSD patients, and (3) the case the study. OV, CFP, AGM, CAC, CFP, CT, DGV, CN and CAS screened the studies
management of PPD may differ from the interventions during the primary search. OV, AGM, CAC, CFP and CAS drafted the first version
of the review. OV, CAC, CFP, DGV, CN and CAS revised the manuscript and
recommended in patients with schizoaffective disorder, major elaborated the review's conclusions. All authors had full access to the data
depression with psychotic features, adverse events of contained in this review and decided to submit the manuscript for publication.
different drugs with CNS depressogenic properties, and other

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 https://doi.org/10.55453/rjmm.2024.127.1.7
The article was received on June 20, 2023, and accepted for publishing on August 3, 2023.
ORIGINAL ARTICLE

Evaluation of Adsorption Therapy as an Extracorporeal Blood Purification Technique in

Critically Ill Covid-19 Patients

Mehmet E. Yuksel1, Nazan H. Selmi2, Caglayan M. Ayaz3, Seval Izdes4

1 Ankara Etlik City Hospital, Surgical Intensive Care Unit, Ankara, Turkey; [email protected]
2 Ankara City Hospital, Department of Intensive Care, Ankara, Turkey; [email protected]
3 Ankara City Hospital, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey; [email protected]

4 Ankara Yildirim Beyazit University School of Medicine, Department of Anesthesiology and Intensive Care, Ankara City Hospital, Ankara, Turkey; [email protected]

Correspondence: Mehmet Eren Yuksel, [email protected]

Abstract: We aimed to evaluate the efficacy of adsorption therapy as an extracorporeal blood purification technique in critically
ill patients with Coronavirus disease 2019 (COVID-19). A retrospective analysis was performed on 17 adult patients with severe
COVID-19, who underwent adsorption therapy using an HA330 cartridge, at Ankara City Hospital. Each adsorption therapy was
administered for three consecutive days, and each therapy session lasted three hours. Several parameters, including cytokine
levels, blood count, biochemistry panel, clinical status, and mortality rate were assessed before and after each therapy session.
The results obtained from this study revealed that adsorption therapy reduced IL-6 levels and improved oxygenation in the short
term. However, heart rate, mean arterial pressure and SOFA score did not demonstrate significant changes. Notably, the dose of
norepinephrine increased after the third session. Regrettably, only 4 out of 17 patients (23.5%) survived. Consequently, adsorption
therapy appears to be effective in reducing IL-6 levels in severe COVID-19 patients. Nonetheless, further investigation is warranted
to evaluate its impact on clinical outcomes.

Keywords: Adsorption therapy; coronavirus disease 2019; cytokine storm; extracorporeal blood purification

INTRODUCTION Patients with COVID-19 have considerably higher levels of

proinflammatory cytokines and chemokines like tumor
COVID-19 infects the airway epithelium, leading to widespread
necrosis factor-α, interleukin 1 and 6, granulocyte-colony
damage, severe inflammation, and pneumonia with a
stimulating factor, monocyte chemoattractant protein-1,
cytopathic effect. A cytokine storm, capillary leak syndrome,
interferon gamma-induced protein-10, and macrophage
lung injury, and Acute Respiratory Distress Syndrome (ARDS)
inflammatory proteins 1-α [7]. In individuals with severe
are all brought on by the local and circulating cytokines that
COVID-19, these proinflammatory cytokines and chemokines
are produced at this time [1-4]. In patients with severe COVID-
lead to a cytokine storm. The extracorporeal removal of these
19, several inflammatory mediators are involved, and the
cytokines from COVID-19 patients' blood circulation using an
cytokine storm has a deleterious impact on the disease's
adsorption therapy is hypothesized to minimize
progression [5].
hyperinflammation and calm the cytokine storm.
Additionally, COVID-19 exhibits immunological dysfunction. Extracorporeal blood purification systems do not only remove
Techniques for extracorporeal blood purification have pathogenic toxins and proinflammatory mediators; they also
previously been utilized as supportive therapy to manage remove regulating cytokines. As a result, their process is non-
immunological dysregulation in the treatment of sepsis [6]. selective. These regulatory cytokines are also advantageous
Despite the use of a variety of treatments, critically ill COVID- because they restrain the immune system from overreacting
19 patients have consistently significant mortality rates. As a to inflammation [8]. Therefore, while the application of
result, the use of cytokine filters as a therapy option for these extracorporeal blood purification procedures may have short-
individuals is now being given further thought. term advantages, its possible adverse effects on long-term

46
outcomes have not yet been thoroughly assessed and material allow the removal of several molecules with different
understood. molecular weights such as free hemoglobin, cytokines,
complements, drugs, uremic toxins, and protein-bound or
An adsorption therapy, which is an extracorporeal blood
hydrophobic substances. The recommended treatment
purification technique can be used as a cytokine filter in severe
duration with an HA330 cartridge is 2-2.5 hours, while the
COVID-19 patients. For this aim, an extracorporeal filter which
sorbent material can be saturated if it is used for a longer
is a cartridge with a sorbent inside is used for blood
period which causes a decrease in clearance efficiency [9,12].
purification by combining convection and diffusion for solute
removal [9]. Additionally, through ionic attraction, In this study, we wanted to assess the efficacy of adsorption
hydrophobic interactions, hydrogen bonds, and van der Waals therapy in patients with severe COVID-19. To understand the
interactions, the sorbent in the cartridge comes into direct effects of adsorption therapy using HA330 cartridges in severe
contact with blood to adsorb solutes [10,11]. The sorbent in COVID-19 patients in the intensive care unit (ICU), we
the cartridge also targets TNF, IL-1, IL-6, IL-10, IL-18, and other evaluated the changes in the clinical status of patients,
cytokines [11]. Thus, cytokines and solutes in the bloodstream cytokine levels, complete blood count, and biochemistry panel
bind to the sorbent material. Therefore, adsorption therapy before and after the administration of the therapy
can also be used for patients with autoimmune diseases,
chronic uremic symptoms, intoxications, and inflammatory MATERIALS AND METHODS
conditions with cytokine storms such as sepsis and pancreatitis
A retrospective analysis was performed on 14 male (82.3%)
[9,12].
and 3 female (17.6%) adult severe COVID-19 patients who
For adsorption therapy in COVID-19 patients, the Jafron HA330 received adsorption therapy (HA330 cartridge, Jafron) in the
cartridge can be used [13]. The neutro-macroporous resin- ICU at Ankara City Hospital between April 2020 and October
adsorbing beads in the HA330 cartridge are constructed of the 2021 (Table 1). Before and after adsorption therapy with
styrene-divinylbenzene copolymer. The resin beads' average HA330, the patients’ laboratory results and clinical outcomes
diameter ranges from 0.60 to 1.18 mm and is 0.8 mm. The were assessed. Ankara City Hospital (E2-21-983) granted
resin's pore sizes range from 500 D to 60 kD, whereas the permission for this study with the approval of the local ethics
HA330 cartridge removes molecular weights from 10 to 60 kDa committee.
(kiloDalton; Dalton [9,12]. Multiple pore sizes of the sorbent

Table 1: Characteristics of severe COVID-19 patients treated with HA330 adsorption cartridge
Characteristics of COVID-19 patients
Demographics
Age (years) (median, IQR) 53.5 (45-62.5)
Gender, male (n, %) 14 (82.3)
female (n, %) 3 (17.6%)
Treatment
Methylprednisolone 40 mg (n, %) 17 (100)
IVIG (n, %) 1 (5.8)
Anakinra (n, %) 9 (52.9)
Tocilizumab (n, %) 1 (5.8)
Outcomes
Length of ICU stay (days) (median, IQR) 22 (34)
Mechanical ventilator duration (days) (median, IQR) 20 (30)
Survived (n, %) 4 (23.5)
Died (n, %) 13 (76.5)
1 IQR: interquartile range. IVIG: intravenous immunoglobulin. ICU: intensive care unit. Anakinra: An interleukin-1 receptor antagonist. Tocilizumab: A monoclonal
antibody against the IL-6 receptor. In this study, 14 male (82.3%) and 3 female (17.6%) adult patients with severe COVID-19 were treated with adsorption therapy
(HA330 cartridge, Jafron©) in the ICU. The median age of the patients was 53.5 (IQR: 45-62.5). All 17 patients received a ten-day course of iv methylprednisolone 40
mg once daily. Of the patients, nine were treated with anakinra, one with tocilizumab, and one received IVIG treatment without tocilizumab or anakinra. Four
patients died after the first adsorption therapy session, and another four died after the second. Nine patients completed three sessions of adsorption therapy, but five
of them died due to sepsis and ARDS-related complications in the ICU. Overall, 4 out of 17 critically ill COVID-19 patients survived after adsorption therapy with an
HA330 cartridge (23.5%).

47
Respiratory distress with peripheral capillary oxygen glomerular filtration rate, urea, albumin, alanine transaminase
saturation (SpO2) 93% in room air, dyspnea with a respiratory (ALT), aspartate transferase (AST), total bilirubin, lactate
rate of at least 30 breaths per minute, a ratio of the partial dehydrogenase (LDH), troponin, fibrinogen, D-dimer, lactate,
pressure of arterial oxygen to the fraction of inspired oxygen ferritin, erythrocyte sedimentation rate, C-reactive protein
(PaO2/FiO2) less than 300 mmHg, and more than 50% (CRP), procalcitonin, interleukin-6 (IL-6), hemoglobin,
infiltration of the lung fields are all considered to be severe neutrophil/lymphocyte ratio (NLR), number of leukocytes,
COVID-19 in adult patients [14]. Moreover, cytokine release neutrophils, lymphocytes, and platelets were noted before
syndrome was defined as having one or more of C-reactive and after adsorption therapy sessions. Additionally, the
protein >100 (or >50 mg/L but doubled in the past 48 hours), patients’ vital signs, requirements for vasopressor
lymphocyte count <0.6 × 109/L, serum interleukin-6 (IL-6) level medications, partial pressure of oxygen to fraction of inspired
higher than 3 times of the upper normal limit, ferritin >300 oxygen (PaO2/FiO2), and Sequential Organ Failure Assessment
ug/L with doubling within 24 hours, ferritin >600 ug/L at (SOFA) scores were recorded from their medical records
presentation and LDH >250 U/L, and elevated D-dimer (>1 before and after adsorption therapy sessions.
mcg/mL) [15]. These 17 patients had confirmed COVID-19
Statistical evaluation was performed using the Statistical
diagnoses based on real-time reverse transcription
Packages for the Social Sciences (v17.0, SPSS 24 Inc., Chicago,
polymerase chain reaction (RT-PCR) test results and ground
IL) software. Categorical data were presented as numbers and
glass appearance with pneumonia on thorax computed
percentages, while quantitative data were presented as mean
tomography before admission to the ICU. They also had
standard deviation or median and interquartile range (IQR), as
previously defined severe COVID-19 disease and cytokine
appropriate. The differences between the two groups were
release syndrome features. The exclusion criteria for this study
evaluated with the Mann-Whitney U test and the Wilcoxon
included being under the age of 18, having severe heart failure
test. The statistical significance level was accepted as p<0.05.
with a left ventricular ejection fraction of less than 35%, having
coagulation issues, and being pregnant.
RESULTS
All 17 patients received methylprednisolone 40 mg iv once
Adsorption therapy with a Jafron HA330 cartridge was applied
daily for ten days. 9 patients were treated with anakinra,
once to 17 patients, twice to 13 patients, and three times to 9
whereas 1 patient was treated with tocilizumab. 1 patient
patients. The median age of the patients was 53.5 (IQR: 45-
received immunoglobulin (IVIG) treatment without
62.5). The median ICU length of stay was 22 (IQR:34) days. The
tocilizumab or anakinra.
median mechanical ventilator duration was 20 days (IQR:30).
Adsorption therapy was initially planned for 3 hours daily with The median APACHE II score was 18 (IQR:10). The median
an HA330 cartridge for 3 consecutive days. However, length of stay in the ICU before the initiation of adsorption
adsorption therapy could be applied to 17 patients once, 13 therapy was 4 days (IQR:2-6) (Table 1).
patients twice, and 9 patients three times. Thus, creatinine,

Table 2: Clinical status of patients before and after 1st, 2nd and 3rd sessions of adsorption therapy with HA330 cartridge
Before adsorption After 1st session After 2nd session After 3rd session
Clinical parameters P* P* P*
therapy (IQR) (IQR) (IQR) (IQR)
PaO2/FiO2 (mmHg) (n=12) 0.59 (0.46-0.92) 0.69 (0.47-0.95) 0.12 0.54 (0.46-0.69) 0.44 0.62 (0.51-0.71) 1.0
HR (bpm/min) (n=13) 87.0 (66.5-100.0) 80.0 (69.5-102.5) 0.72 77.0 (67.5-120.0) 0.86 90.0 (72.8-113.8) 0.74
MAP (mmHg) (n=14) 80.0 (73.8-102.5) 80.0 (68.8-97.5) 0.44 75.0 (65.0-92.5) 0.23 71.5 (61.2-96.0) 0.53
Dose of NE (µg/kg/min) (n=9) 0.12 (0.04-0.43) 0.15 (0.03-0.67) 0.46 0.04 (0.12-0.17) 0.89 0.25 (0.07-0.19) 0.11
2Numerical data were given as a median and interquartile range (IQR). PaO2/FiO2: partial pressure of arterial oxygen/the fraction of inspired oxygen. HR: Heart rate.
MAP: Mean arterial pressure. NE: norepinephrine. SOFA: Sequential Organ Failure Assessment. *Wilcoxon test was used.

The first, second, and third sessions of adsorption therapy to these findings, the first adsorption therapy session led to a
using the HA330 cartridge are shown in Table 2 along with the statistically significant increase in PaO2/FiO2 levels (p=0.03),
patients’ clinical status before and after each session. For each whereas the second and third sessions did not. None of the
clinical parameter, including PaO2/FiO2, heart rate (HR), mean three sessions of adsorption therapy resulted in statistically
arterial pressure (MAP), norepinephrine dose (NE), and significant changes in heart rate, mean arterial pressure, or
Sequential Organ Failure Assessment (SOFA) score, the median SOFA score.
and interquartile range (IQR) are shown in the table. According
The dose of NE showed a statistically significant increase after

48
the third session of adsorption therapy (p<0.11). Overall, these significant increase in leukocyte count after the first
data imply that the use of an HA330 cartridge in adsorption adsorption therapy compared to the leukocyte count before
therapy may improve oxygenation in patients with severe adsorption therapy (12.2 to 14.6, p=0.02). However, the
COVID-19, but larger sample sizes and additional research are leukocyte count decreased from 14.6 to 12.9 after the 2nd
required to confirm these results. session and increased to 13.5 after the 3rd therapy session,
neither of which was statistically significant (p=0.42, p=0.12,
Table 3 shows the variations in cytokine levels, complete blood
respectively). When compared to the neutrophil count prior to
counts, and biochemistry panels in severely ill COVID-19
the first adsorption therapy (10.9 to 13.6, p=0.03), there was a
patients receiving first, second, and third adsorption therapy
statistically significant rise in neutrophil count.
sessions using HA330 cartridges. A statistically significant
decrease in IL-6 levels was observed after the first, second, and However, the neutrophil count climbed to 12.1 after the third
third adsorption therapy sessions (361, 86.5, 28, 20.3, p<0.03, therapy session but declined to 11.6 after the second (p=0.46
p<0.03, p<0.007, respectively). There was a statistically p=0.19). Neither change was statistically significant (Table 3).

Table 3: Statistical analysis of laboratory parameters of severe COVID-19 patients before and after first, second, and third sessions of adsorption
therapy with HA330 cartridge
Before adsorption
Laboratory After 1st session After 2nd session After 3rd session
therapy P* P* P*
parameters (n=17) (IQR) (n=13) (IQR) (n=9) (IQR)
(n=17) (IQR)
Hemoglobin (g/dL) 11.6 (9.1-12.7) 11.0 (9.4-12.9) 0.64 11.0 (10.1-12.4) 0.48 11.0 (9.1-11.6) 0.22
Leukocyte Count x109/L 12.2 (9.1-14.3) 14.6 (9.7-21.0) 0.02 12.9 (8.8-20.2) 0.42 13.5 (8.9-14.6) 0.12
Neutrophil Count x109/L 10.9 (7.8-13.4) 13.6 (8.2-19.3) 0.03 11.6 (7.1-19.2) 0.46 12.1 (7.7-13.0) 0.19
Lymphocyte Count x109/L 0.64 (0.39-0.77) 0.62 (0.42-0.80) 0.96 0.55 (0.43-0.70) 0.92 0.48 (0.38-0.78) 0.82
Platelet count x109/L 262.0 (200.0-303.0) 274.0 (162.0-328.0) 0.47 266.0 (195.0-350.0) 0.75 213.0 (175.0-307.0) 0.60
NLR 20.2 (15.9-32.8) 28.8 (17.9-42.1) 0.03 24.3 (22.1-49.7) 0.20 23.4 (18.7-29.3) 0.80
Glucose mg/dL 189.5 (114.3-236.8) 211.0 (146.5-224.0) 0.51 153.0 (128.0-205.5) 0.38 151.0 (118.5-210.5) 0.53
Creatinine mg/dL 0.93 (0.56-1.93) 0.86 (0.64-2.0) 0.64 1.0 (0.73-2.40) 0.03 1.09 (0.62-1.30) 0.26
Estimated GFR ml/min/m2 88.0 (41.0-118.0) 94.0 (43.5-112.5) 0.60 78.0 (30.0-99.5) 0.11 83.5 (59.0-108.0) 0.25
Urea mg/dL 62.0 (42.8-98.0) 65.5 (50.3-132.8) 0.06 84.5 (52.3-161.3) 0.07 73.0 (64.0-105.0) 0.24
Albumin g/L 29.0 (26.0-32.0) 28.0 (22.5-31.5) 0.04 30.0 (28.3-31.8) 0.20 28.0 (26.3-30.8) 0.49
ALT U/L 46.5 (27.8-126.8) 59.0 (30.0-200.0) 0.55 51.0 (30.0-225.5) 0.64 66.0 (26.0-100.5) 0.99
AST U/L 37.0 (27.3-81.0) 59.0 (32.5-228.0) 0.84 58.0 (22.5-180.5) 0.51 45.0 (21.0-63.0) 0.30
Total bilirubin mg/dL 0.9 (0.5-1.2) 0.8 (0.5-1.2) 0.84 0.6 (0.5-0.8) 0.18 0.75 (0.4-1.3) 0.21
Troponin Ng/L 49.0 (8.8-423.1) 114.4 (24.0-647.0) 0.74 186.0 (22.8-360.7) 0.07 - -
INR 1.4 (1.2-1.7) - - 1.3 (1.2-1.48) 0.60 - -
Fibrinogen g/L 6.4 (3.7-7.2) 6.5 (3.8-7.3) 0.51 5.7 (3.4-7.8) 0.65 5.0 (1.6-7.0) 0.64
D-dimer mg/L 5.8 (1.9-13.6) 4.9 (2.4-7.3) 0.35 8.6 (1.8-17.7) 0.44 7.90 (4.4-22.0) 0.98
Lactate 2.3 (1.6-3.2) 1.9 (1.3-2.9) 0.07 1.8 (1.4-2.4) 0.21 - -
LDH U/L 600.5 (516.8-766.5) 659.0 (543.0-963.5) 0.65 671.0 (468.5-889.0) 0.97 578.5 (488.8-674.5) 0.39
Ferritin ml/ng 961.0 (393.5-1540.0) 1500.5 (880.3-5546.0) 0.06 1461.0 (1025.5-3667.0) 0.58 1236.5 (377.5-1611.5) 0.12
ESR mm/h 56.0 (21.8-108.3) 78.0 (15.0-125.0) 0.07 65.0 (22.5-103.0) 0.72 - -
CRP mg/L 0.16 (0.13-0.218) 0.15 (0.13-0.25) 0.51 0.15 (0.09-0.17) 0.10 0.10 (0.06-0.14) 0.09
Procalcitonin µg/L 1.01 (0.17-11.3) 4.2 (0.28-11.6) 0.44 0.53 (0.22-8.84) 0.35 0.19 (0.11-0.58) 0.06
IL-6 pg/mL 361.0 (68.2-739.8) 86.5 (10.9-167.7) 0.03 28.0 (20.8-76.9) 0.03 20.3 (7.6-32.4) 0.007
3 Numerical data are given as a median and interquartile range (IQR). NLR: neutrophil-lymphocyte ratio, GFR: glomerular filtration rate, ALT: Alanine transaminase,
AST: Aspartate transferase LDH: lactate dehydrogenase, INR: international normalized ratio, ESR: erythrocyte sedimentation rate, CRP: C-reactive protein, IL-6:
interleukin-6. (-): data could not be retrieved. There was a statistically significant decrease in IL-6 levels after the first, second, and third adsorption therapy sessions
(361, 86.5, 28, 20.3, p <0.03, p<0.03, p<0.007, respectively). *Wilcoxon test was used

49
There was a statistically significant increase in the neutrophil- the number of white blood cells and thrombocytes increased
lymphocyte ratio (NLR) after the first adsorption therapy to the normal range whereas IL-6, CRP, and fibrinogen levels
compared to the NLR before adsorption therapy (20.2 to 28.8, decreased [17]. According to Villa et al., treatment with oXiris
p=0.03). Although the NLR dropped from 28.8 to 24.3 after the resulted in a significant drop in IL-6 levels as well as
second session and then further to 23.4 after the third (p=0.20 improvements in hemodynamic stability, multiorgan
and p=0.80, respectively), neither of these decreases was dysfunction, and oxygenation index in 37 patients [18].
statistically significant. When compared to the albumin level
Case studies of COVID-19 patients who received treatment
before the initial adsorption therapy, there was a statistically
with a CytoSorb filter were described by Rizvi et al., Melegari
significant drop in albumin (29.0 to 28.0, p=0.04). However,
et al., and Berlot et al. [1, 19, 20]. All three patients survived
albumin increased from 28.0 to 30.0 after the second session
with an improvement in CRP, IL-6, and oxygenation. Rieder et
and reduced to 28.0 after the third (p=0.20 and p=0.49,
al. treated 4 patients under venovenous extracorporeal
respectively), neither of which was statistically significant.
membrane oxygenation (vv-ECMO) support with cytokine
No statistically significant changes were observed in adsorption with CytoSorb filter, which decreased IL-6 in
creatinine, glomerular filtration rate, urea, alanine COVID-19 patients [21]. According to Alharthy et al.,
transaminase (ALT), aspartate transferase (AST), total continuous renal replacement therapy (CRRT) sessions using a
bilirubin, lactate dehydrogenase (LDH), troponin, fibrinogen, CytoSorb cartridge were administered to 50 patients. Thirty-
D-dimer, lactate, ferritin, erythrocyte sedimentation rate, CRP, five patients who survived after CytoSorb therapy had
procalcitonin, hemoglobin, glucose, lymphocyte, or platelet decreased ferritin, lactate dehydrogenase, CRP, IL-6, and D-
count after the first, second, and third sessions of adsorption dimer levels [15].
therapy with HA330 cartridges. Four patients died after the
According to Olson et al., the Seraph-100 filter was utilized in
first, and another four patients died after the second
two COVID-19 patients, and as a result, post-treatment
adsorption therapy session. Nine patients completed three
vasopressor dose, IL-6, and CRP levels decreased [22]. The use
sessions of adsorption therapy. However, five of these nine
of a Seraph-100 filter on a patient with COVID-19 significantly
patients died due to sepsis and ARDS-related complications in
decreased D-dimer level, according to Pape et al. [23]. Four
the ICU. Only 4 out of 17 critically ill COVID-19 patients
hemodialysis patients with severe COVID-19 were treated
survived after adsorption therapy with an HA330 cartridge
using a Seraph-100 haemoperfusion device, according to
(23.5%).
Sandoval et al. Despite findings from other research, Sandoval
et al. failed to find any appreciable drop in IL-6, D-dimer, or
DISCUSSION
ferritin levels following the treatment [24]. According to
There are a limited number of publications in the English Schmidt et al., 78 COVID-19 patients who received treatment
medical literature related to the use of extracorporeal blood with a Seraph-100 microbind affinity blood filter were
purification techniques with the United States Food and Drug evaluated. According to Schmidt et al, patients who received
Administration (FDA) approved filters such as oXiris filter Seraph-100 treatment within 60 hours of ICU admission had a
(Baxter, Deerfield, IL), CytoSorb filter (CytoSorbents, reduced mortality rate [25].
Monmouth Junction, NJ), Seraph 100 Microbind blood affinity
Reverse Takotsubo cardiomyopathy associated with COVID-19
filter (ExThera Medical, Martinez, CA) and the Spectra Optia
was treated with therapeutic plasma exchange utilizing a
Apheresis System with the Depuro D2000 Adsorption
Spectra Optia apheresis system outfitted with a Depuro D2000
Cartridge (Terumo BCT, Lakewood, CO) for the treatment of
adsorption cartridge, according to Faqihi et al. Following
COVID-19 patients [8]. According to Padala et al., using an
treatment, both lactate levels and left ventricular function
oXiris filter improved clinical outcomes in two out of three
returned to normal [26].
patients and reduced levels of interleukin-6, erythrocyte
sedimentation rate, and CRP [16]. According to Zhang et al., Koc et al. published a review of hemadsorption therapy in
CRP, IL-6, IL-8, IL-10, APACHE II, and Sequential Organ Failure severe COVID-19 patients [13]. 86 patients with severe COVID-
Assessment (SOFA) scores all significantly decreased after 19 were included in 16 trials that were examined by Koc et al.
oXiris filter treatment, while IL-4, IL-8, and procalcitonin CytoSorb®, oXiris®, Biosky filter, SeaStar® CLR filter, HA280,
showed a nonstatistically significant downward trend. HA330 Jafron, and resin-directed hemadsorption cartridges
Unfortunately, two of five patients passed away despite were used in hemoperfusion therapy. According to Koc et al.,
treatment [2]. Ugurov et al. reported using oXiris in ten the mortality rate, mean intubation time, and length of stay in
patients with COVID-19. Two of the ten patients passed away the ICU and hospital were, respectively, 29%, 14.93 days, 17.21
related to complications of ARDS. According to Ugurov et al., days, and 31.7 days. Following hemoperfusion sessions, the

50
mean levels of CRP and interleukin-6 reduced (131.7 to 66.0 adsorption therapy as a salvage therapy when the patients did
and 527.5 to 334.7, respectively). According to Koc et al., not respond to other treatment options such as antibiotics,
hemoperfusion and cytokine adsorption reduced cytokine corticosteroids, hydroxychloroquine, immunoglobulin,
levels, CPR, and IL-6 relative to pre-therapy, decreased convalescent plasma, tocilizumab or anakinra [33].
mortality to 29%, and improved clinical conditions. However,
There is still no single laboratory parameter with a cut-off
these outcomes lacked statistical significance. Hemadsorption
value identified to initiate adsorption therapy. Moreover, the
therapy was described by Koc et al. as an alternate salvage
duration of therapy and the parameters to monitor the
therapy for COVID-19 patients who were critically unwell.
patient’s response to the treatment are still under
Moradi et. al reported a 73-year-old male patient was treated
investigation [6]. Unfortunately, there is no universally
with hemoperfusion (HA230 cartridge, Jafron) due to a
accepted standardized adsorption therapy protocol. We
cytokine storm for 4.5 hours [27]. Moradi et al. claimed that
preferentially used adsorption therapy to treat severely ill
the symptoms and need for oxygen support were alleviated
COVID-19 patients with low procalcitonin but high CRP and IL-
during hemoperfusion treatment.
6 levels.
Theoretically, blocking the formation of proinflammatory
Except for a decline in IL-6, we were unable to find a
cytokines can reduce hyperinflammation. The clinical outcome
statistically significant link between the quantity of adsorption
of severely ill COVID-19 patients can be improved by reducing
therapy sessions and laboratory values. The majority of the
hyperinflammation. Thus, anti-interleukin-6R monoclonal
research previously cited showed that adsorption treatment
antibodies and corticosteroids were recommended to reduce
reduced IL-6 levels. However, anakinra and tocilizumab might
the inflammatory response. However, IL-6 promotes
be responsible for the IL-6 decline in COVID-19 patients [34].
neutrophil-mediated viral clearance by initiating a preliminary
response against viral infections [7]. Moreover, Dienz et al. Moreover, our study has certain drawbacks. First of all, the
reported that IL-6 or IL-6 receptor-deficient mice could not sample size was quite small. Secondly, during the pandemic,
resist Influenza A infection, which caused pulmonary damage we mostly served severe COVID-19 patients in our intensive
leading to death [28]. Despite its theoretical benefit, Clark et care unit, which restricts the applicability of our findings to
al. reported that hemoperfusion was an experimental other patient populations. Finally, because a control group was
treatment because of its limited evidence of efficacy [29]. not included in our investigation, additional variables, such as
However, Kang et al. reported that in patients with severe medication modifications and illness progression, might have
COVID-19 and non-acute kidney injury, continuous renal an impact on the observed changes in laboratory values.
replacement therapy using an oXiris filter might not be able to Hopefully, our study contributes to the growing body of
successfully reduce cytokine release syndrome [30]. research on the use of adsorption therapy in COVID-19
patients despite these limitations.
Hemadsorption therapy has several additional drawbacks.
Arrhythmia, coagulation issues, thrombocytopenia, and
CONCLUSION
bleeding were listed as the most typical short-term
hemoperfusion consequences in patients with COVID-19 by After examining this study's data, it can be concluded that in
Darban et al. [31]. However, the majority of the difficulties patients with severe COVID-19, the use of an HA330 cartridge
emerged on the second and third days following during adsorption therapy was connected to a statistically
hemoperfusion, not during hemoperfusion itself. significant drop in IL-6 levels after the first, second, and third
therapy sessions. Except for a rise in the leukocyte and
A highly biocompatible sorbent covered with a surface that
neutrophil counts following the first session, there were no
inhibits platelet adherence and clotting activation is necessary
statistically significant associations between the quantity of
for hemoperfusion. The various sorbent types utilized
adsorption therapy sessions and other laboratory findings.
determine how hemoperfusion removes substances, with the
effective surface area being a key factor. The sorbent material To draw a definitive conclusion about the effect of adsorption
within the hemoperfusion cartridge can both absorb and lead therapy with HA330 cartridges on COVID-19 patients, further
to the loss of antibiotics and nutrients from the bloodstream studies with larger and more diverse patient populations are
[9, 10, 32]. needed. These studies should also consider other potential
confounding factors, such as the administration of other
The Jafron HA330 cartridge was the only available single-use
treatments and underlying medical conditions. Nevertheless,
hemoperfusion cartridge at Ankara City Hospital. Thus, we
the findings of this study point to the possibility that
performed adsorption therapy on severe COVID-19 patients in
adsorption therapy could be a potential supplementary
the ICU with single-use Jafron HA330 cartridges. We used
treatment option for individuals with severe COVID-19.

51
Conflicts of interest and sources of funding editing, N.H.S., C.M.A., M.E.Y., S.I.; visualiza-tion, M.E.Y.; supervision, S.I.; project
The authors declare no conflict of interest. This research received no external administration, S.I. All authors have read and agreed to the published version of
funding. the manuscript.

Authors’ contribution Ethics approval and consent to participate

Conceptualization, M.E.Y, N.H.S., C.M.A., S.I.; methodology, M.E.Y., S.I.; The study was conducted under the Declaration of Helsinki, and local ethics
software, M.E.Y.; validation, N.H.S., C.M.A., M.E.Y., S.I.; formal analysis, M.E.Y.; committee approval for this study was obtained from Ankara City Hospital (E2-
investigation, M.E.Y.; resources, N.H.S., C.M.A., M.E.Y., S.I.; data curation, N.H.S, 21-983).
C.M.A, M.E.Y., S.I.; writing-original draft preparation, M.E.Y.; writing-review and

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The article was received on April 17, 2023, and accepted for publishing on August 12, 2023.
ORIGINAL ARTICLE

Psychometric Properties of the Method "Evaluation of Negative Mental Reactions and States
of Combatants" and Experience of its Application in Short-term Psychological Recovery

Yanina Matsegora1, Oleksandr Kolesnichenko2, Ihor Prykhodko1, Viktoriia Kuzina3, Vitalii Panok4, Andrii Pashchenko5, Serhii
Shandruk6, Natalia Penkova7, Stanislav Larionov5
1 Research Center, National Academy of National Guard of Ukraine, Kharkiv, Ukraine; [email protected] (YM), [email protected] (IP)
2 Department of Professional Psychology, National Academy of the Security Service of Ukraine, Kyiv, Ukraine; [email protected]
3 Department of General Military Disciplines, Ukrainian Military Medical Academy, Kyiv, Ukraine; [email protected]

4 Ukrainian Science Methodological Center of Applied Psychology and Social Work of NAES, Director, Kyiv, Ukraine, [email protected]

5 Department of Psychology and Pedagogy, National Academy of National Guard of Ukraine, Kharkiv, Ukraine, [email protected] (AP),

[email protected] (SL)
6 Department of Psychology and Social Work, West Ukrainian National University, Ternopil, Ukraine, [email protected]

7 Department of Social, Humanitarian and Law Disciplines, Kyiv Institute of the National Guard of Ukraine, Kyiv, Ukraine. [email protected]

Correspondence: Oleksandr Kolesnichenko, [email protected]

Abstract: The article shows the development of the method of psychological evaluation called “Evaluation of Negative Mental
Reactions and States of Combatants”. In the study participated 1300 male servicemen (29.84% from junior lieutenant to colonel
and servicemen under contract and demobilized, and 70.16% from private to senior warrant officer). The age of participants
varied from 20 to 55 years. The system of evaluation developed consisted of 16 instruments that could help to determine the
presence of negative psychological symptoms of servicemen related to their participation in hostilities. The results indicated that
the evaluation method developed is a tool that allows determining the presence of negative psychological symptoms related to
participation in combat. Likewise, it is a useful and fast method to assess the effectiveness of short-term psychological recovery
programs. Unlike existing methods of diagnosing negative mental reactions and states of an individual, which arose after their
participation in hostilities, the developed psychodiagnostic toolkit could consider the physical and mental fatigue of the
respondents, their deterioration, and other cognitive dysfunctions.

Keywords: combat activity, psychological rehabilitation, psychological recovery, post-traumatic stress disorder, evaluation
system

INTRODUCTION perform tasks under the conditions of combat stress factors

action [5].
Long participation in hostilities depleted the psychological
adaptation resources of servicemen, sharply posing the Nowadays, the psychological decompression measures were
question concerning the need for psychological recovery [1,2]. directed not only to ensuring the adequacy of switching from
This issue was complicated and comprehensive; it related both military service to peaceful life [6], including traditional stress
to the definition of rotation of servicemen and to the relief and help in civilian life realization, taking into account the
determination of the duration and development of effective acquired military experience, accepting this experience to
programs of psychological recovery for all participants of reduce the probability of post-traumatic stress disorders
hostilities [3] as well as to the determination of indications for (PTSD) formation [7,8], but also for the psychological
medical and psychological rehabilitation of the servicemen, restoration of mental health of servicemen who participated
whose mental health and ability to readaptation was lost [4]. in hostilities to relieve the accumulated stress prolonging the
The aim of psychological recovery was to restore the physical possibility of adequate functioning of servicemen under
and mental resources of servicemen to prolong their ability to combat conditions when it was impossible to realize the

54
massive rotations to keep their resistance – psychological 4) able to clearly demonstrate changes in psychological state
stability, ability to resist negative influence from the side of that occurred during their participation in the psychological
combat stress factors [2]. To the institutions of psychological recovery program;
recovery were sent the servicemen with expressed signs of
5) convenient for summarizing data and receiving the
maladjustment [9], acute stressful reactions [7], significant
psychologist's feedback on the effectiveness of the
exhaustion, devastation, and fatigue [10], and servicemen,
introduction of new actions into the programs of psychological
who had difficulties in adaptation [11] while getting back in
recovery;
line after injuries and concussion and after their stay in
hospitals. 6) useful for obtaining information related to the effectiveness
of individual consulting, providing a psychologist with a
Institutions that implemented psychological recovery
reflection on his/her professional activity. With existing
programs were located in the third echelon of defense in safe
pressure on psychologists, there occurred a need for
places in order to form in the minds of servicemen the idea of
supervision and their rotation in institutions that dealt with
the need to return to the performance of combat missions,
psychological recovery.
and military duty, which was a way of posing the direction of
recovery – the restoration of combat capacity. The objective of the study was the development of a
psychological evaluation system of the consequences of
Realization of activities of psychological rehabilitation and
participation in combat activities for military personnel
implementation of existing psychological programs of
participating in hostilities. Unlike the existing systems to
decompression on the basis of their personal professional
diagnose the psychological consequences of combat
experience and world experience of rehabilitation of
participation, it is intended to develop a set of
servicemen was imposed on the military psychologists of the
psychodiagnostic tools that assess the physical and mental
Armed Forces and the National Guard of Ukraine, as well as on
fatigue of combatants, their deterioration, and other cognitive
the volunteer psychologists from NGOs who had appropriate
dysfunctions. And also, that it is capable of clearly showing the
training and experience. Usually, the implementation of
psychological changes achieved by participation in
psychological recovery programs was a combination of
psychological recovery programs.
procedures of medical treatment orientation with the use of
appropriate material and technical bases and the involvement
MATERIALS AND METHODS
of appropriate specialists.
Participants and Procedure
Even though the system of implementation of the
psychological restoration of combat servicemen was well- The study was conducted in 2022. The study included 1300
established and proved its effectiveness in practice, there servicemen who underwent a psychological recovery program
arose a question on the development of effective after taking part in a long combat mission. The tested group
psychodiagnostic tools of the mental state control of consisted of officers – 29.84% (from junior lieutenant to the
servicemen before and after a complex of actions by the colonel) and servicemen under the contract and mobilized –
program of psychological rehabilitation for individual 70.16% (from private to senior warrant officer). The age of the
servicemen and correction of the recovery program if study participants varied from 20 to 55 years.
required. There were distinguished the following
While developing the method "Evaluation of negative mental
requirements for the psychodiagnostic method:
reactions and states of combatants", there were combined the
1) convenient while conducting both individual and group simplest procedures of conditions evaluation which were
psycho-diagnosis of servicemen, typical for a survey with a typical for the method such as "Profile of mood states" (POMS)
large number of people (100-200 people), capable of taking [12,13], "Self-esteem of psychophysiological state" (Kokun)
into account the physical and mental fatigue of the [14], "Measurement of states" used to express evaluation of
respondents, deterioration of their attention, and other emotional states of sportsmen [15]. Also, there was conducted
cognitive dysfunctions related to stressful experience; analysis of negative mental reactions and states that often
occurred in servicemen while their participation in hostilities,
2) suitable for the diagnosis of negative mental reactions and
including those who described the ability to perform tasks and
conditions that occur after participation in hostilities;
the ability to interact with others in the performance of
3) reliable for re-diagnosis due to a minor period of time, command work [1,16]. Thus, the list of negative mental
excluding the ability to remember accurately their past reactions and states (experience) was quite wide and
answers; contained 16 points: irritability; anxiety; aggressiveness;

55
anger; inattention; self-doubt; devastation; apathy; concern; standardized on the Ukrainian selection.
sense of guilt; sense of powerlessness; lack of concentration;
Method "Maladjustment" (Prykhodko, Matsegora,
unwillingness to communicate; lack of trust in comrades in the
Kolesnichenko, and Baida) [17] was an express version of the
service; lack of trust in commanders; inability to perform the
method "Adaptability" (Maklakov) [22] which had a long
assigned tasks. It was assumed that the use of factor analysis
tradition of use in the Armed Forces of Ukraine. The
would give the possibility to group these points into the scale.
"Adaptability" method was concluded by military psychologist
It was necessary to point out that the simplicity of the A.H. Maklakov [22] to determine the adaptation potential of
instructions and of the testing procedure itself was an servicemen based on the individual scales of the method
important circumstance for effective diagnostic work with "Minnesota Multiphasic Personality Inventory" (McKinley,
servicemen who had been experiencing the influence of Hathaway) [23]. The developer reported satisfaction with the
combat stress factors for a long time and who had difficulty in psychometric characteristics of the formed methodology [22].
the redistribution of attention. Since the beginning of hostilities in eastern Ukraine among
military psychologists of Ukraine, there was spread a
However, a number of points (16) of the evaluation of negative
modification of the methodology proposed by Maklakov
mental states but the evaluation scale itself (from 0 to 10
"Adaptability 200", carried out by Chermianin and Kondratiev
points) was quite large (exceeding the amount of short-term
[24]. Unlike the previous method, it was supplemented with a
memory 7±2 elements), which complicated their
number of issues that allowed us to distinguish "military and
memorization and accuracy reproduction during re-testing.
professional orientation", "tendency to deviant behaviors",
The determination of psychometric indicators of the method and "suicidal risk" and to calculate "the level of resistance to
“Evaluation of negative mental reactions and states of combat stress". This method included 200 questions; thus,
combatants” and its testing was carried out during the there was a need to form a simpler and more reliable toolkit,
participation in a psychological recovery program by which was the basis for the development of an express version
servicemen. 1300 servicemen participated at this stage. of the method. The developed method "Maladjustment"
(Prykhodko, Matsegora, Kolesnichenko, and Baida) [17] was
The servicemen filled out the form of the method at the
aimed at the identification of specific violations of adaptation
beginning of the psychological recovery program and after it.
potential which could have a big influence on the ability to
The results obtained in accordance with the method
adequately perform the tasks. Thus, the method had 4 scales,
“Evaluation of negative mental reactions and states of
each with 10 questions – "Violation of behavioral regulation",
combatants” were compared with the results of methods that
"Probability of committing suicidal attempts", "Violation of
were conducted with servicemen to control their condition
moral normativity" and "Loss of communicative potential".
before and after their participation in the psychological
There was highlighted the calculation of the general indicator
recovery program. Before participating in a psychological
of "Maladjustment". This calculation was simple and
recovery program, servicemen were surveyed with the
convenient and could be carried out under field conditions
following methods: “Maladjustment” (Prykhodko, Matsegora,
without any additional tools. Although working with the
Kolesnichenko, and Baida) [17], “Mississippi Scale for Combat-
method involved the presence of trust in psychologists, the
Related PTSD” (Keane, Caddell, and Taylor) [18], “Diagnostics
method had a scale of sincerity. The developers provided data
of psychological safety of an individual” (Prykhodko, 2012)
about the satisfactory psychometric indicators of the method.
[19], “Evaluation of traumatism of combat experience of
servicemen” (Kolesnichenko) [20]. After participating in the The study used the "Mississippi Scale for Combat-Related
psychological recovery program, servicemen were surveyed in PTSD" (Keane, Caddell, and Taylor), which was restored for the
accordance with the following psychodiagnostic methods – Ukrainian selection [18]. Nowadays, it was one of the most
“Resistance to psychological traumatism of combat common methods used to measure the signs of PTSD. The
experience” (Kolesnichenko) [21]. scale included 35 statements, each of which can be estimated
on a five-point scale. The total indicator which was made up in
All procedures in the study conformed to the ethical standards
accordance with this method gave the possibility to estimate
of the 1964 Helsinki Declaration and its later amendments. All
the degree of influence of the traumatic experience
participants consent for their data to be used in this research.
transferred by an individual.
Instruments and Measures
"Diagnosis of Psychological Safety of an Individual"
To determine the constructive validity of the method (Prykhodko), which was developed on the basis of the concept
"Evaluation of negative mental reactions and states of of psychological safety of an individual of specialists of
combatants" there were used methods which were extreme activities [19]. According to this concept,

56
psychological safety was not only a lack of danger but also an met 3 groups of combat stress factors and 2 factors that
opportunity for development and self-realization. described internal and external resources used to counteract
Psychological safety had a level structure. Each level in the stress factors. In the process of standardizing the method,
method met a scale with a similar name. The first level was there was used the procedure of regressive analysis which
moral and communicative, it meant that knowledge and use of gave the possibility to determine the contribution of each scale
the rules of communication and norms of morality made to acute stress disorder which occurred due to the action of
interaction with the social environment controlled and combat stress factors. It was reported that the method had
predictable, formed the ability to escape potentially conflict satisfactory psychometric characteristics.
situations, and involved external resources to overcome
The method "Resistance to psychological traumatism of
problematic situations. The motivational and volitional levels
combat experience" (Kolesnichenko) [21] was developed on
suggested that the developed goal setting, intensity in goal
the basis of the author's concept of combat psychological
setting, and flexibility in their corrections could ensure the self-
traumatism of servicemen [1]. The method reflected the given
realization of an individual in difficult conditions of life. It was
in this concept three levels (stages) of realization of resistance
assumed that the ability to flexible restructuring of relations
to the action of combat stress factors, which 1) were related
with the environment gave the possibility to be leading in
to the preparation for activity under the conditions of combat
these relationships, to control them. The valuable and
stress factors and under the existing expectations concerning
semantic level was considered as an ability to conscious
the stress factors’ activity and their ability to overcome them,
attitude to one's own life, awareness of one's own influence
2) had the direct ability to overcome stressful influence and
on the world, and responsibility for its changes. The developer
used adequate situational copings, and 3) had the ability to
believed that this conscious attitude gave the possibility for an
accept and realize the acquired experience under the stressful
individual to tolerate life difficulties and sufferings that arose
conditions. There was provided the calculations of general
in the process of self-realization. Moreover, due to the
resistance to combat psychological traumatism. It was
developer, the hierarchy of the semantic sphere gave the
reported that this indicator had a reverse correlation with the
possibility to depreciate the experience in frustration as
"Mississippi Scale for Combat-Related PTSD" (Keane, Caddell,
unimportant and to consolidate efforts to achieve important
and Taylor) [18], r = -0.60, p≤0.01. Moreover, the method of
aims. The level of internal comfort was the factor that
the scale of the second order – "helplessness", "conscious
provided a change in the direction of activity. Thus, the
attitude to professional training", "ability to acquire
evaluation of life as safe, and the condition as comfortable
experience", "cognitive dysfunction", and "attitude to military
contributed to the decision to continue normal regulation. The
duties". The method had satisfactory psychometric indicators.
decisions related to the changes were made in case of non-
compliance of the environment with the needs and capabilities Data Analysis
of an individual. There was highlighted the calculation of the
To represent the data, there was used the main descriptive
general indicator of psychological safety of an individual, its
statistics (arithmetic mean M and standard deviation SD). To
height indicated the ability to set new goals of self-realization.
distinguish the correlational rate between the variables there
When the indicators were reduced the thing was in a
was used the correlation analysis. To determine the internal
supportive reproduction of usual goals of life or in the arrest
coherence of the method "Evaluation of negative mental
of development, and further impossibility of self-realization.
reactions and states of combatants" there were used
The developed method had satisfactory psychometric
calculations based on Cronbach's alpha. To determine the
indicators. The National Guard of Ukraine had been using this
specific negative mental reactions and states which were
method for more than 10 years.
experienced by servicemen due to their participation in
The method of "Evaluation of traumatism of combat hostilities there was used regression analysis. To determine
experience of servicemen" [20] was based on the American the structure of the method "Evaluation of negative mental
method "Combat Exposure Scale" [25]. In the process of its reactions and states of combatants" there was used factor
development, there were considered the traumatic events and analysis with the help of the method "Principal components".
their intensity which were typical for military actions in Mathematical data was processed with the help of SPSS 17.0.
Ukraine with the beginning of the Russian invasion in 2014.
Unlike the "Combat Exposure Scale" method, the method of RESULTS
"Evaluating of traumatic experience of servicemen"
We have developed the following form of psychodiagnostic
(Kolesnichenko) had been developed; it included a list of
method "Assessment of negative mental reactions and states
phenomena that gave the possibility to reduce the trauma of
in combatants" (Table 1). The instructions are as follows:
combat stress factors influence. The method had 5 scales that

57
"Please assess your psychological state at the moment on a Cronbach indicator, which was 0.944 having the selection of
scale from 0 - slightly expressed, 10 - strongly expressed". The 1300 people for 16 indicators.
internal consistency of the method was evaluated using the α-

Table 1: Form of the methodology "Evaluation of negative mental reactions and states of combatants"
Mental reactions and states Evaluation of reactions and states
Irritability 0 1 2 3 4 5 6 7 8 9 10
Anxiety 0 1 2 3 4 5 6 7 8 9 10
Aggressiveness 0 1 2 3 4 5 6 7 8 9 10
Anger 0 1 2 3 4 5 6 7 8 9 10
Inattention 0 1 2 3 4 5 6 7 8 9 10
Self -doubt 0 1 2 3 4 5 6 7 8 9 10
Devastation 0 1 2 3 4 5 6 7 8 9 10
Apathy 0 1 2 3 4 5 6 7 8 9 10
Concern 0 1 2 3 4 5 6 7 8 9 10
Sense of guilt 0 1 2 3 4 5 6 7 8 9 10
Sense of powerlessness 0 1 2 3 4 5 6 7 8 9 10
Lack of concentration 0 1 2 3 4 5 6 7 8 9 10
Unwillingness to communicate 0 1 2 3 4 5 6 7 8 9 10
Lack of trust in comrades in the service 0 1 2 3 4 5 6 7 8 9 10
Lack of trust in commanders 0 1 2 3 4 5 6 7 8 9 10
Inability to perform the assigned tasks 0 1 2 3 4 5 6 7 8 9 10

Despite the fact that the developed method included negative factor structure of the method was a certain confirmation of
mental reactions and states for evaluation of PTSD, and less regularity of negative mental reactions and states, a
maladjustment, and testified both negative experiences and reflection of greater integration of mental processes while
inability to manage their behavior, its purposefulness and operating under stressful conditions.
inability to maintain interaction and consistency in teamwork,
The determination of the validity of the method was
factor analysis which was conducted in accordance with
conducted in two stages. In the first stage, to determine the
"Principal Components" presented the presence of only one
constructive validity, the data of the method "Evaluation of
factor that included all 16 variables with different factors of
negative mental reactions and states of combatants" was
factor evaluation: "irritability" (0.743), "anxiety" (0.796),
compared with the data of methods which gave the possibility
"aggressiveness" (0.692), "anger" (0.722), "inattention"
to diagnose the peculiarities of negative mental reactions and
(0.744), "self-doubt" (0.744), "devastation" (0.808), "apathy"
states of servicemen, proving that they were related to their
(0.733), "concern" (0.808), "sense of guilt” (0,793), "lack of
participation in hostilities. First of all, the talk was about the
concentration " (0.801), "unwillingness to communicate"
method "Maladjustment" which gave the possibility to
(0.714), "lack of trust in comrades in the service" (0.640), "lack
evaluate the violation of "behavioral regulation", "the
of trust in commanders" (0.675), "inability to perform the
probability of committing suicidal attempts", "violation of
assigned tasks" (0.746).
moral normativity" and "loss of communicative potential" by
Taking into account the received data, the method included servicemen [17], and "Mississippi Scale for Combat-Related
the calculations of general indicators. Experience using the PPSD” (Keane, Caddell, and Taylor) [18], which gave the
method had shown that the most convenient indicator was the possibility to diagnose PTSD symptoms of those who had
calculation of the average arithmetic value for all 16 indicators. participated in hostilities and left the battlefield [24].
Thus, the general indicator had a range from 0 to 10 points, Moreover, there was used the method of "Evaluation of
which was convenient to perceive general results by the traumatic experience of servicemen" (Kolesnichenko) [20] and
method and did not require memorization of additional "Resistance to psychological traumatism" (Kolesnichenko)
information for manual data processing. [21], which in this study gave the possibility to connect the
experience of negative mental reactions and states with the
It was necessary to point out that the selection of a single-

58
experience of participation in hostilities, as well as with their Considering such purpose, the data obtained by the method
peculiarities and preparation for them. "evaluation of negative mental reactions and states of
combatants" before and after the participation in the recovery
Correlational relations with the method of "Diagnosis of
program was compared to the data obtained by Lüsher's color
psychological safety" (Prykhodko) [19] indicated the depth of
test including the indicator of anxiety. This indicator pointed
violation of personality structures, which ensured its safety
out the availability of frustrated needs and inadequacy of
and ability to develop, which was an important factor for
compensation and, unlike other indicators by this projective
making a prognosis for the restoration of an individual in the
method, could be confused with indicators by other methods.
process of psychological decompression and rehabilitation.
The indicator of anxiety in accordance with Lüsher's color test
The results of correlational analysis, which were obtained at
was used as an integrated state evaluation since the main
this stage of validity determination were given in Table 2.
determinants of mental states were the ratio: firstly, conscious
Considering that the selection of the study at this stage
and unconscious needs, desires, and aspirations of an
included 1300 people, then all the correlational indicators
individual; secondly, the capabilities of an individual (obvious
given reached the level of statistical significance and did not
abilities and hidden potentials); thirdly, environmental
require additional indicators.
conditions (objective influence and subjective perception of
Dense correlation relations of the method "Evaluation of the current situation) [25].
negative mental reactions and states of combatants" and
40 servicemen participated at this stage of the study. Thus, the
methods such as "Maladjustment" (Prykhodko et al.) [17] and
general indicator by the method "evaluation of negative
"Mississippi Scale for Combat-Related PTSD" (Keane, Caddell,
mental reactions and states of combatants" correlated with
and Taylor) [18] pointed out that according to the data
anxiety before the beginning of the decompression program at
provided by the developed method, it was really possible to
a moderate level – r = 0.41, p≤ 0.01; after the decompression
consider negative experience, which was connected with
program the data was – r = 0.47, p≤ 0.01. These data proved
adaptation disorders and PTSD symptoms. The data provided
that the developed method was sensitive to the changes in
by the method "Evaluation of traumatic experience of
states and could be used to evaluate the dynamics of states
servicemen" [20] proved that negative experience was mostly
during the programs of psychological recovery which were
related to the force of negative effects than to the existing
developed for short-term (up to a week).
external support.
It was figured out that the general indicator (see Table 2) had
However, the formed personality structure (according to the
a slightly higher density than individual indicators by the
method "Diagnosis of Psychological Safety” [19] including the
method "evaluation of negative mental reactions and states of
process of professional and professional-psychological
combatants" with general indicators of maladjustment, PTSD,
training, due to the method "Evaluation of traumatism of
psychological safety of an individual, traumatism of combat
combat experience of servicemen" [20] was able to restrain
experience, and resistance to psychological traumatism. It was
the development of negative states, providing adequate
another piece of evidence that the method would be more
functioning of an individual under combat conditions. But at
reliable if it was used as a single scale.
this stage, it was impossible to monitor the accumulated
influence of traumatic events on the development of negative Then there was used the procedure of regression analysis to
mental states while exceeding the recommended time for determine specific negative mental reactions and states
rotation (more than 6 months). experienced in these psychological categories; thus, there
were formed relevant regression equations:
The second stage of determination of the method’s validity
Maladjustment = 3.804 + 0.216*Irritability + 0.307*
was developed to determine its ability to be a tool for tracking
Aggressiveness + 0.259*Self-doubt + 0.249*Devastation +
the dynamics of changes during psychological recovery. The
0,245*Concern + 0.386*Reluctance to communicate + 0.229*
methods which were used at the first stage had satisfactory
Lack of trust in comrades in the service + 0.350*Lack of trust
indicators of reliability, and, therefore, could be insensitive to
in commanders +0.264* Inability to perform the assigned
the changes which occurred during the week (this was a usual
tasks + 0,529.
term of the program of psychological recovery of servicemen).
Post-traumatic stress disorder = 54.66 + 1,070*Irritability +
The method of "evaluation of negative mental reactions and
0.719*Aggressiveness + 0.572*Inattention + 0.557*
states of combatants" was developed specifically for
Devastation + 1.230*Apativity + 0.794*Concern + 0.613*
evaluating the control of negative states’ changes before and
Unwillingness to communicate + 0.602*Lack of trust in
after participation in the psychological recovery program,
commanders +0.941* Inability to perform the assigned tasks
including the possibility to evaluate its effectiveness.
+0.506.

59
Table 2: The indicators of correlative relations between the scales of method "Evaluation of negative mental reactions and states of
combatants" and the scales of other psychodiagnostics methods which were used to estimate its validity (in points).

60
 Psychological safety of an individual = 5.325 – indicator had expressed PTSD symptoms. When the average
0.072*Irritability – 0.064*Devastation – 0,077*Sense of guilt quantity of points was 5.5% – 100% of servicemen who
– 0,095*Sense of powerlessness – 0.071* Reluctance to participated in psychological recovery activities had an
communicate + 0.775. indicator that exceeded the norm by the "Mississippi Scale for
Combat-Related PTSD" (Caddell and Taylor) [18].
Traumatism of combat experience = -17.672 + 0.426*Anxiety
+ 0.393*Apathy + 0.502*Inability to perform the assigned The comparison with the data provided by the method
tasks + 0.789. "Resistance to psychological traumatism of combat
experience" showed that with general points 3 or more in
Resistance to combat psychological traumatization = 167.165
accordance with the method "Evaluation of negative mental
– 2.514*Anxiety + 2.869*Anger – 1.621*Apathy – 1,510* Lack
reactions and conditions of combatants" 75.59% of
of trust in comrades in the service – 4.812*Inability to
servicemen with such quantity of points were diagnosed with
perform the assigned tasks + 0.599.
an unsatisfactory indicator of resistance (from 0 to 143 points).
The procedure of regression analysis had to give the possibility
If the general indicator was exceeded in accordance with the
to reduce the dimension of measurements for each state, but
method "Evaluation of negative mental reactions and states of
as it could be seen, the error of evaluation in the concluded
combatants" the score of 5 points meant that low resistance
regression equations was quite high, especially in the process
to combat psychological traumatism was diagnosed in almost
of predicting traumatism of combat experience (e = 0.789) and
86% of servicemen who participated in psychological recovery
psychological safety of an individual (e = 0.775) that made it
activities.
inappropriate to use them for calculations. However, the
information obtained through regression analysis gave the The comparison with the express method "Psychological
possibility to better understand the experience of servicemen Safety of an Individual" (Prykhodko) [19] and "Evaluation of
who had different negative symptoms due to their traumatism of combat experience of servicemen”
participation in hostilities. (Kolesnichenko) [20] pointed out that if the points were less
than 3 by the general scale of the method "Evaluation of
Moreover, a long-last period of testing and a large selection of
negative mental reactions and states of combatants" 89% of
the study had shown that the calculations made with the help
servicemen retained satisfactory indicators of psychological
of regression analysis by individual scales were less accurate
safety of an individual, and 85.41% were diagnosed with low
than the normalized general indicator by the method (that
trauma of combat experience.
indicated one more time the importance of using the method
as a single scale). It was the regulation for different negative More reliable for these two methods was a forecast
symptoms that prevailed in determining the ways of concerning psychological well-being than negative symptoms.
processing data by the method.
Thus, the given data showed that for the general indicator by
Thus, the obtained data showed that if the general indicator the method "Evaluation of negative mental reactions and
by the method "Evaluation of negative mental reactions and states of combatants" it was normal to have a high probability
states of combatants" exceeded 3.5 points, then 65.45% of of negative symptoms’ absence (PTSD, maladjustment,
servicemen-participants of the psychological recovery instability to combat psychological traumatization, and
program were likely to be symptoms of maladjustment by the psychological safety of an individual) and it also showed that
same method. If the average points according to the high ability to recover was possible when an indicator was less
developed method were 5 or more, then more than 85% of than 3 points.
servicemen with this indicator were diagnosed with expressed
It was necessary to point out that the results obtained with the
symptoms of maladjustment.
help of the method, both individual and group ones, were
The comparison of the general indicator by the method convenient to present in the form of column histograms. As an
"evaluation of negative mental reactions and states of example, there was proposed the histogram of the dynamics
combatants" with the method "Mississippi Scale for Combat- of negative mental reactions and conditions of servicemen
Related PTSD" (Keane, Caddell, and Taylor) [18] showed that with signs of maladjustment (in particular, violation of
while exceeding 3.5 points according to the scale of the behavioral regulation) in the process of one of the
developed method more than 90% of servicemen with this decompression courses (Figure 1).

61
 Figure 1: Dynamics of negative mental reactions and conditions while participating in psychological recovery in a group of servicemen with
violation of behavioral regulation (in points)

Notes: 1 – inability to perform the assigned tasks; 2 – lack of trust in commanders; 3 – lack of trust in comrades in the service; 4 – unwillingness to communicate; 5 –
lack of focus; 6 – sense of impotence; 7 – sense of guilt; 8 – concern; 9 – apathy; 10 – devastation; 11 – self-doubt; 12 – inattention; 13 – anger; 14 – aggressiveness;
15 – anxiety; 16 – irritability

DISCUSSION
Traditionally, in clinical practice, there had been used for a
According to Ukrainian [14] and foreign specialists [26,27], long time the projective method such as Lusher's color test, in
early diagnosis of negative mental reactions and states [28], particular after psychotherapy and training activities for self-
post-stress states, and determination of a group of increased regulation and restoration of adaptive capacity, the selection
psychological attention among personnel gave the possibility of colors could be compared with the so-called autogenic norm
to identify servicemen with low personal adaptive potential by Wallnöfer [37].
and high probability of early and severe manifestations of
World tendencies in psychological studies showed that the
combat psychological traumas [29] and its consequences [30];
diagnosis of mood, mental reactions, and conditions was
also gave the possibility to create individual tactics and
relevant not only for the needs of the clinic but also in the
methods of prevention and restoration of each surveyed
workplace. The study of workers’ moods and states was an
serviceman. To solve the problem of diagnosis of negative
important component of the psychological well-being (health)
mental reactions and states of servicemen, it was suggested to
of workers. These studies were extremely large-scale and
use the following psychodiagnostic tools: "The Hospital
attracted thousands of working people as participants [38].
Anxiety and Depression Scale (HADS) ", "Brief Scale of Anxiety,
Such interest in the problem of studying the state of a working
Depression, and PTSD", "The Montgomery-Asberd Depression
person, as an indicator of his/her psychological well-being, was
Rating Scale (MADRS)” [31], "Beck Depression Inventory (BDI)"
quite clear since the psychological state was a holistic,
[32], "Primary Screening for Post-Traumatic Stress Disorder
systematic, integral formation of human psychological activity.
(PTSD)", "Mississippi Scale for Combat-Related PTSD" (Keane,
The psychological state of an individual could be internally and
Caddell, and Taylor) [18], "Impact of Event Scale–Revised (IES-
externally observed, it acted as a regulatory function of
R)" [33], "Patient Health Questionnaire (PHQ)-9" [34],
adaptation to the external situation and environment [16].
"Clinical-administered PTSD Scale" [35], "Neurotization and
According to the definition by Kirilenko, the psychological state
Psychopathization (LNP) questionnaire" [14] and others. As an
was the formation of psychological activity, which reflected
additional diagnostic tool, at the request of a psychologist,
the moment of stability and specificity of psychological
there was used the method "The Suicidal Behaviors
processes’ duration, as a form of response, and reflected the
Questionnaire-Revised (SBQ-R)" [36] to diagnose the suicidal
attitude of an individual toward his/her own psychological
inclinations of servicemen. However, this psychological study
phenomena at a certain point in time under certain conditions
could have been placed under the conditions of medical and
[39]. Varii pointed out that the psychological state was a
psychological rehabilitation which lasted not less than two
temporary functional level of the psyche, which reflected the
weeks, but it was quite difficult to realize this tool under the
interaction of the influence of the internal environment of the
conditions of psychological recovery, which lasted not more
body or external factors and determined the orientation of
than one week.

62
psychological processes’ duration at a certain moment and reduce the dimension of POMS [41]. For this purpose, the
manifestation of psychological properties of an individual [40]. POMS scale [12,13] with the help of regression analysis
The author defined the following areas in the studies of mental correlated with "The Eight State Questionnaire" (8SQ) [42],
states: 1) mental states were an integral characteristic of the which was formed to measure anxiety, stress, depression,
psyche at a particular moment; 2) psychological states were regression, fatigue, guilt, extraversion, and excitement.
the background on the bases of which operated the Researchers found that the excessiveness of measurement
psychological activity and orientation of the psychological between these two methods mainly referred to negative
activity of an individual; 3) it was a systemic reaction of the emotional states.
human psyche to changes of the conditions.
CONCLUSIONS
Volzhentseva highlighted that the leading functions of mental
states were the regulation and integration into functional Thus, the developed method "evaluation of negative mental
units, which were formed in the hierarchy of a single, holistic reactions and states of combatants" was a tool that gave the
set of psychological processes and properties [25]. According possibility to determine the presence of negative
to the author, the adaptive function of the psychological state psychological symptoms of servicemen related to their
was to establish the correspondence between the current participation in hostilities and was a convenient tool for
needs and capabilities of an individual, considering the estimation of the dynamics of the state under the conditions
external conditions, features of activity, and behavior. of short-term programs of psychological recovery without the
use of complex evaluation procedures and calculation of data.
It was likely that the integration and integrity of psychological
states became the basis for reducing the dimensions of the
methods which were intended for their research. Thus, in Conflicts of interest and sources of funding
The authors declare no conflict of interest. No financial support was received
foreign scientific sources, it was reported that to determine
from any governmental institution, economic or non-governmental organization.
the moods and conditions, which were important indicators of
short-term effects of intervention, was also used in clinical Authors’ contribution
practice, "The Profile of Mood States (POMS)" [12,41]. This Conceptualization, O.K. and YaM.; managed the project, I.P.; conducted the
research, V.K. and V.P.; contributed to the final draft of the manuscript, A.P., S.S.
scale was developed by American experts, it had the form of a
and N.P.; substantiated the methodology, S.L. All authors have read and agreed
self-report and included 65 elements that related to 7 different to the published version of the manuscript. All authors have read and agreed to
scales: depression, anxiety, fatigue, energy, irritability, the published version of the manuscript.
tension, and confusion.
Patient consent for publication
The answer scale was divided into 5 categories from "not at Informed consent was obtained from all subjects for inclusion in the study while
all" to "completely yes". However, German psychologists in maintaining their confidentiality. Written informed consent has been obtained
from all subjects to publish this paper.
the re-standardization of POMS [12,13] created a shortened
version of the method that included only 35 points which Ethics approval and consent to participate
belonged to the scale "Depression/anxiety", "Fatigue", All procedures followed were in accordance with the ethical standards of the
Helsinki Declaration of 1975, as revised in 2000.
"Energy" and "Irritability" [38]. Another study was intended to

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 https://doi.org/10.55453/rjmm.2024.127.1.9
The article was received on June 23, 2023, and accepted for publishing on September 6, 2023.
ORIGINAL ARTICLE

Associations Between Medical Students' Opinions on Usage of Internet Services and Digital
Teaching Tools

Cristina G. Dascălu1, Magda E. Antohe2, Raluca S. Costache3, Victor L. Purcărea4

1 Medical Informatics and Biostatistics Department, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania;

[email protected]
2 3rd Dental Medicine Department, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Iasi, Romania; magda.antohe @umfiasi.ro

3 Internal Medicine & Gastroenterology Department, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania;

[email protected]
4 Marketing and Medical Technology Department, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania; [email protected]

Correspondence: Magda E. Antohe, [email protected]; Raluca S. Costache, [email protected]

Abstract: Currently, the educational process must integrate new tools, to keep pace with technological progress. Our paper aims
to investigate the extent to which the preferences of medical students for the autonomous use of multimedia resources in the
learning process are correlated with their opinions towards the Internet and the intensity of using it in their daily activities.
Methods: We investigated 395 medical students from 4 medical universities in Romania, 75.9% females, and 88.8% in the 1st and
2nd years of study. Students were asked to express on Likert-scales their agreement with a list of statements about Internet
services, as well as whether they like learning using multimedia tools and how intensively they use Internet services. Results: The
students agree to a medium to large extent with the favorable statements about Internet services but are also aware of the
negative influences that indiscriminate use of such technology can have. The intensity of Internet usage is high, although not
exaggerated. With small exceptions, the students who enjoy using multimedia resources during the learning process have also
favorable opinions about Internet services, and use them constantly, mainly for information and instant messaging on social
networks.

Keywords: multimedia-based learning; blended learning; Internet services; social networks; medical students

INTRODUCTION "Generation Z" (children born after 1997), also known as iGen,
post-millennial, or digitally native. These are children who
Currently, digital technology has become increasingly used in
have been exposed to technology from the beginning of their
everyday activities, and its intensive use in most fields of
lives, so using computers and gadgets has become second
activity has attracted changes in the structure of society, and
nature to them, as have the activities online and on social
even in the psychology of individuals, who gradually change
networks. Consequently, these children prefer to study
their conceptions about life, work, and education, about the
independently, at their own pace, using visual or kinaesthetic
ideal way of spending leisure time and about the features of
didactic tools, which give them immediate feedback. It is
an optimal work climate. In this general context, it is obvious
important for them to respect the right to privacy and personal
that the educational process must integrate new tools, in an
space; they are pragmatic, entrepreneurial, and generally
attempt to keep pace with technological progress. The
reluctant to take risks (because they faced periods of
protagonists of this process, students as well as teachers, are
economic recession in childhood); although they generally
people with a fundamentally different lifestyle than 20 years
enjoy interaction with the teacher, Generation Z children have
ago, with different expectations and conceptions.
fewer social skills associated with face-to-face communication
The most obvious changes are noticed in the case of the and the art of conversation, compensated instead by intense
current generation of students. This is the so-called online activity [1].

66
There are currently relatively few studies in the literature but also than full online courses. A 2009 report from the
concerning Generation Z issues, which usually focus on United States examined 51 studies comparing online and
describing its characteristics [2,3], effective strategies for traditional methods and concluded that students enrolled in
recruitment in the public sector [4], and individuals' attitudes blended learning programs score on average better on exams
towards work [5], but without focusing on the specific than those enrolled in full-onsite programs [6]; on the other
problems of medical students of this generation, with their hand, blended teaching programs also perform better than
own needs, preferences and learning styles. fully online ones as well [7], as they still give to the students
the opportunity to interact effectively with the teacher when
Obviously, the learning style of Generation Z students has
needed.
features that differentiate it from the learning styles preferred
by other generations of students. The most preferred method - Clearer organization of content: It is the natural result of a
is active learning (through discussion and involvement in well-designed blended course, which must provide students
practical projects), based on sensory stimuli (visual - images, with clear and detailed indications of using the proposed
graphics, auditory and kinetic). Knowledge is achieved through resources, activities, and tests, helping them to concentrate
observation, practice, and quick and targeted access to the better and proposing an optimal pace of learning, in the same
necessary information through the use of technology and way that the teacher guides students onsite in going through
online resources: e.g. YouTube for video tutorials, Facebook the exposed materials;
(for chatting with classmates and sharing projects and
- Stimulation of active learning, which emphasizes the
teaching materials), or Google (for documenting and searching
student’s autonomy in effective learning communities;
for scientific references). Students prefer self-study, at their
own pace, with a flexible schedule and teaching materials that - Lower costs: Reducing the number of onsite meetings frees
intensively use multimedia resources: explanatory or up the teaching spaces of the institution and reduces some
demonstrative video sequences, PowerPoint presentations utility expenses. The teachers and the students will gain lower
with audio support, simulations, collaborative projects, transport costs and time savings, although logistics expenses
discussion forums, online questionnaires, and case studies in can be slightly increased (it is necessary to purchase adequate
the classical environment (seminar room or practical works). personal computers and involves additional costs for
In this context, the portrait of the ideal teacher has also electricity consumption and telephone subscription).
changed significantly: firstly, he must be a good
Our paper aims to investigate the extent to which the
communicator, close and friendly, transparent, enthusiastic,
preferences of students at medical faculties for the
passionate and competent in his field, able to propose realistic
autonomous use of multimedia resources in the learning
goals and to provide immediate and constructive feedback on
process are correlated with their opinions towards the online
their achievement, willing to provide professional and
environment and the Internet and the intensity with which
emotional support to his students, both academically and
they use such resources in their daily activities, not necessarily
individually, to prepare them for their future careers.
related to the learning process.
In this context, the concept of blended education, based on
the intensive integration of digital resources into the teaching MATERIALS AND METHODS
process, is becoming increasingly popular among teaching
We conducted a case study that enrolled 395 medical students
tools.
from 4 medical universities in Romania. The general features
Such education programs are usually developed in mixed of the sample are shown in Table 1. Students are 3 quarters
regimes, online and onsite, combining as much as possible in females (75.9%); most students are in the 1st and 2nd years of
an optimal manner the advantages of both methods. Blended study (88.8%), aged between 18-20 years (74.4%), with an
courses are a current trend that provides a new and effective average age of 21.78 ± 3,736 years and a range of variation
instructional experience to the students they address, and between 18-48 years.
have several major advantages:
Also, most students come from faculties of Dental Medicine
- Flexibility in the teaching schedule, which simplifies students' (34.4%) or General Medicine (47.6%), mainly from the "Grigore
access to the course, regardless of their physical location and T. Popa" University of Medicine and Pharmacy in Iasi, Romania
allows them to organize their time and pace of learning (50.9%); 27.1% of the participating students are from
according to their own needs and availability; University of Medicine and Pharmacy in Craiova, and 20.3%
from University of Medicine and Pharmacy "Victor Babeș" in
- More effective teaching: Most scientific studies show that
Timisoara.
blended teaching is more effective than traditional courses,

67
Students were invited to fill in an online questionnaire in order Comparisons between samples were made using the Kruskal-
to express their agreement degree with a list of statements Wallis test for quantitative data, after having previously
about Internet services (favorable – 7 items and unfavorable – verified that they comply with the normal distribution law,
3 items). In addition, they were asked whether they like using the Shapiro-Wilks normality tests. We considered the p-
learning using multimedia tools and resources and how value ≤ 0.05 to be statistically significant (*) and the p-value ≤
intensively they use different Internet services (7 items). 0.01 to be statistically highly significant (**).

The agreement degree with the proposed statements was

RESULTS
quantified using a 5-step Likert scale, ranging from 1 – very
small agreement to 5 – very large agreement. The 7 favorable statements about the Internet were as follows:
- Item 1: The main advantage of the Internet is that it provides
Table 1: General features of the study sample information fast;
n % - Item 2: The main advantage of the Internet is that it provides
masculine 95 24.1 correct information;
Gender
feminine 300 75.9 - Item 3: Freedom of expression should not be restricted on
18-20 years 294 74.4 the Internet;
Age group 21-24 years 78 19.7 - Item 4: Most people would not be able to cope if they no
over 25 years 23 5.8 longer had access to the Internet;
1 228 57.7 - Item 5: I can't imagine my life without Internet access;
Year of study 2 123 31.1 - Item 6: People who socialize on the Internet are happier than
3 44 11.1 others;
Dentistry 136 34.4 - Item 7: If I didn't socialize on the Internet I would be sadder.
General medicine 188 47.6 88.6% of students evaluate the Internet as a fast source of
Specialization
Dental technique 70 17.7 information (item 1) but are more reserved about its
Prophylaxis assistance 1 0.3 correctness (only 30.6% of them think that information on the
UMPh Iasi 201 50.9 Internet is much or very much correct – item 2).
UMPh Craiova 107 27.1
University 68.9% of students believe that most people would not be able
UMPh Timișoara 80 20.3
UMPh Cluj Napoca 7 1.8
to cope if they no longer had access to the Internet (item 4)
and 60.7% believe that they themselves would not be able to
Total 395 100.0
cope if there is no Internet (item 5). 53.9% of students believe
The questionnaire was presented and explained individually to that freedom of expression should not be limited to the
each study participant. Internet (item 3).

Participation in the study was voluntary. Participants were On the other hand, only a small percentage of students believe
informed about the study and the overall objectives of the that socializing in the virtual environment ensures a
research and, at the beginning of the questionnaire, were comfortable psychological status, making them happier (item
invited to give their informed consent. The questionnaires 6 – 10.9%, respectively item 7 – 21.5%) – Table 2.
were completed anonymously. The 3 unfavorable statements about the Internet were as
The study was approved by the Research Ethics Commission of follows:
the "Grigore T. Popa" University of Medicine and Pharmacy, - Item 8: Internet is addictive;
Iasi (decision no. 21/16.11.2020). - Item 9: Parents should limit their children's access to Internet
to at most one hour;
Statistical analysis - Item 10: People's privacy is at risk due to social media.
Data collected from students were recorded and processed in A large part of students believe that the Internet can be
SPSS 29.0 (SPSS Inc., Chicago, IL) for Windows. addictive (item 8 – 76.2%). Although they generally do not
The responses to each item were characterized by frequency consider it necessary for parents to limit their children's access
distributions and contingency tables. The numerical variables to the Internet (item 9 – only 41.0% agree to a large or very
were characterized by descriptive statistics (mean, standard large extent), they still believe that people's privacy is at risk
deviation, standard error, range of variation, and median). due to social networks (item 10 – 59.5%) – Table 3.

68
 Table 2: Favourable opinions about Internet services – students’ responses
Agreement:
Favorable opinions
1 – to a very small 3 – in average 5 – to a very large
about Internet 2 – to a small extent 4 – to a large extent
extent measure extent
services
n % n % n % n % n %
Item 1 1 0.3 4 1.0 40 10.1 125 31.6 225 57.0
Item 2 8 2.0 49 12.4 217 54.9 93 23.5 28 7.1
Item 3 9 2.3 16 4.1 157 39.7 107 27.1 106 26.8
Item 4 7 1.8 25 6.3 91 23.0 143 36.2 129 32.7
Item 5 21 5.3 35 8.9 99 25.1 115 29.1 125 31.6
Item 6 81 20.5 121 30.6 150 38.0 34 8.6 9 2.3
Item 7 75 19.0 118 29.9 117 29.6 46 11.6 39 9.9

Table 3: Unfavourable opinions about Internet services – students’ responses

Agreement:
Unfavorable opinions
1 – to a very small 3 – in average 5 – to a very large
about Internet 2 – to a small extent 4 – to a large extent
extent measure extent
services
n % n % n % n % n %
Item 8 3 0.8 17 4.3 74 18.7 139 35.2 162 41.0
Item 9 43 10.9 56 14.2 134 33.9 94 23.8 68 17.2
Item 10 10 2.5 44 11.1 106 26.8 118 29.9 117 29.6

The consumer of Internet services profile was outlined favorable: 41.5% of students say they like much or very much
through another 7 questions, regarding the way, intensity, and to learn using multimedia tools, 38.0% of students agree on
main purposes for which students use Internet services. The average with this statement, and only 20.5% of students show
recorded responses are shown in Table 4. a total or partial disagreement (Table 5).

Most students (97.5%) say they use the Internet daily, and In order to express more precisely the obtained results, we
70.9% of them use the Internet at least 3 hours a day. Almost quantified them as numerical scores, calculated as arithmetic
1/3 of students (29.4%) believe that they could not give up the averages of the responses. We calculated 2 scores, one for
Internet without problems even for a day - which indirectly favorable opinions about Internet services (INTF) and one for
means acknowledging an addiction to this practice. On the unfavorable opinions (INTNF), with a range of variation
other hand, half of students (47.6%) indicate the one-week between 1 – 5, which we interpreted as follows:
period as the maximum limit for opting out of the Internet, - Values between 1.00 – 1.49 = agreement to a very small
which is also a limited time frame. Most students access the extent;
Internet using their mobile phones (84.6%). - Values between 1.50 – 2.49 = agreement to a small extent;
- Values between 2.50 – 3.49 = agreement in average measure;
Although they use online services quite intensively, the main
- Values between 3.50 – 4.49 = agreement to a large extent;
objective of students is not written communication – thus,
- Values between 4.50 – 5.00 = agreement to a very large
almost 3 quarters of them (71.6%) say they receive/send
extent.
between 1 - 10 emails per day, and 9.4% say they do not use
Using the same procedure, we calculated also a third score, to
e-mail at all. Half of students (52.4%) are active on social
characterize the intensity in using Internet services (INTS) –
networks, having over 100 friends; however, there is also a
with a range of variation between 1 – 4 and interpreted
significant percentage of students (20.8%) who have fewer
accordingly:
than 10 friends online. In contrast, 74.2% of students post on
- Values between 1.00 – 1.49 = very low intensity;
social media only a few times a year or a few times a month.
- Values between 1.50 – 2.49 = low intensity;
Therefore, students use social networks in a relatively
- Values between 2.50 – 3.49 = high intensity;
moderate regime, mainly for instant communication and less
- Values between 3.50 – 4.00 = very high intensity.
for permanent posts.
The analysis of these scores reveals that students agree to a
Finally, the students were asked whether they liked learning, medium to large extent with the favorable statements about
even autonomously, using multimedia tools and resources Internet services (INTF = 3.44 ± 0.590), but also with the
(Item 18). The answers to this question are generally unfavorable statements about these services (INTNF = 3.69 ±

69
0.817), being therefore aware of the negative influences that of Internet usage is high, although not exaggerated (INTS =
indiscriminate use of such technology can have. The intensity 2.85 ± 0.350) – Table 6.

Table 4: Intensity and main purposes in using Internet services – students’ responses
n %
several times a month 3 0.8
Item 11. On average, I access the Internet: several times a week 7 1.8
daily 385 97.5
less than 1 hour 7 1.8
Item 12. On average, the amount of time I spend on 1 - 3 hours 108 27.3
the Internet during a day is: 3 - 6 hours 145 36.7
over 6 hours 135 34.2
1 year 25 6.3
Item 13. I could quit the Internet without problems 1 month 66 16.7
for a time frame of: 1 week 188 47.6
not even a day 116 29.4
a desktop 13 3.3
a laptop 47 11.9
Item 14. Generally, I access the Internet using:
a tablet 1 0.3
a mobile phone 334 84.6
none 37 9.4
1 to 10 283 71.6
Item 15. On average, the number of emails I
11 to 30 58 14.7
receive/send daily is:
31 to 50 12 3.0
over 50 5 1.3
under 10 82 20.8
between 11 and 50 68 17.2
Item 16. The number of friends (contacts) I have on
between 51 and 100 38 9.6
the most frequently used social network is:
between 101 and 500 109 27.6
over 500 98 24.8
none 35 8.9
several times a year 152 38.5
Item 17. On average, the frequency with which I post
several times a month 141 35.7
new information on my social media profile is:
several times a week 55 13.9
several times a day 12 3.0

Table 5: General opinion about the use of multimedia resources during the learning process – students’ responses
Agreement:
1 – to a very small 3 – in average 5 – to a very large
General opinion
extent 2 – to a small extent measure 4 – to a large extent extent
n % n % n % n % n %
Item 18: I like to learn 19 4.8 62 15.7 150 38.0 81 20.5 83 21.0
using multimedia tools
and resources

Table 6: Internet services usage scores - descriptive statistics parameters

Standard Standard
Mean
n deviation error of the Min Max Median
(M)
(SD) mean (SEM)
Favourable opinions about Internet usage (INTF) 395 3.44 0.590 0.030 1.57 5.00 3.43
Unfavourable opinions about Internet usage (INTNF) 395 3.69 0.817 0.041 1.00 5.00 3.67
Internet usage intensity (INTS) 395 2.85 0.350 0.018 1.71 3.71 2.86

70
We compared these scores according to the students’ degree entertainment in leisure time should also enjoy using them
of agreement with the usage of multimedia resources during professionally, respectively during the learning process.
the learning process, to identify the possible links between
The obtained results are presented in Table 7 and actually
these two elements. We started with the hypothesis that the
validate this research hypothesis.
students who enjoy using digital technologies for

Table 7: Internet services usage scores – compared according to the degree of agreement with the use of multimedia resources during the
learning process
Agreement:
1 – to a very 2 – to a small 3 – in average 4 – to a large 5 – to a very
small extent extent measure extent large extent Kruskal-
Wallis test
M ± SD M ± SD M ± SD M ± SD M ± SD
Favorable opinions about Internet usage H = 23.634
3.02 ± 0.705 3.43 ± 0.612 3.32 ± 0.545 3.53 ± 0.522 3.67 ± 0.593
(INTF) p < 0.001**
Unfavorable opinions about Internet H = 5.414
4.02 ± 0.842 3.68 ± 0.692 3.74 ± 0.807 3.58 ± 0.733 3.63 ± 0.973
usage (INTNF) p = 0.247
H = 12.310
Internet usage intensity (INTS) 2.75 ± 0.415 2.97 ± 0.325 2.81 ± 0.350 2.88 ± 0.324 2.80 ± 0.358
p = 0.015*

There are statistically significant differences between the students are statistically significant.
scores of favorable opinions about Internet usage, determined
by the degree of agreement with the use of multimedia DISCUSSION
resources during the learning process. The lowest scores are
The data from the literature prove that multimedia resources
found in students who agree to a very small extent with the
are an effective tool for learning because they are able to
use of multimedia resources (3.02 ± 0.705), and the highest in
stimulate the students' interest [8] and improve their cognitive
students who agree to a very large extent with the use of
skills [9], also contributing to the development of
multimedia resources (3.67 ± 0.593), so these 2 elements are
supplementary skills – like empathy [10,11] or the academic
in clear correlation.
writing [12]. Such tools are preferred by medical students
The situation is different for the scores of unfavorable because they tend to be kinaesthetic learners, who use
opinions: the highest score of unfavorable opinions about multiple ways to present a topic for a better understanding
Internet usage is found in students who strongly disagree with [13,14,15] – observations also confirmed by our study.
the use of multimedia resources in the learning process (4.02
Medical students are advanced users of smartphones and
± 0.842). As the degree of agreement with the use of
laptops and easily use such devices during their daily activities
multimedia resources increases, the score of unfavorable
and learning [15,16] – a fact also confirmed by our results. The
opinions decreases, but with random fluctuations, so the
students investigated by us are generally interested in digital
observed differences are not statistically significant.
technologies and their applicability during the learning process
The lowest score of Internet usage intensity is also found in [15].
students who strongly disagree with the use of multimedia
It is thus natural that our students have generally positive
resources in the learning process (2.75 ± 0.415) – therefore
opinions about Internet services, without thinking that they
they are fundamentally against digital technologies. On the
are addicted to them. Moreover, they are even aware of the
other hand, the highest score of Internet usage intensity (2.97
presence of such a risk, which proves realistic and mature
± 0.325) is observed in students with little agreement for the
thinking. Most students use the Internet for information,
use of multimedia resources in the learning process – so they
although they are also aware of the risk of not obtaining
are obviously not against digital technologies but probably
accurate data – a fact confirmed by other literature data as
prefer to use them exclusively for leisure. Students who agree
well [17]. We must admit that the media and entertainment
to a medium or large extent with the use of multimedia
tools familiar to previous generations (TV, radio, written press)
resources in the learning process have scores of Internet usage
have now been joined by new, equally important, or even
intensity between the 2 categories mentioned above, so they
more important partners – the smart devices, which seem to
enjoy using digital technologies both professionally and for
have become the most convenient ways to access virtual
leisure. The differences between the investigated categories of
environments.

71
Almost all students use the Internet daily, from their mobile multimedia resources during the learning process are also
phones, and most of them for at least 3 hours – which shows constant users of Internet services, which they use mainly for
a certain degree of dependence on this technology, although information, but also for activities on social networks (mainly
it is not recognized as such. The most frequently used Internet instant messaging) – a fact also confirmed by previous studies
services are, according to some authors, WhatsApp (as a fast in the literature [21,22,23].
communication solution) [18,19,20], YouTube, and Blackboard
[21]. CONCLUSIONS

It is also interesting to note that socializing in cyberspace is not Technology is only a tool that can improve the teaching
very important for our students and does not replace real process, but not only by itself. Those who are responsible for
socialization. Only half of the students have many friends on change are the teachers, who can improve the students’
social media, but even they don't post very frequently (only a outcomes by using technology to convey knowledge,
few times a year or a few times a month, which is a moderate streamlining their methods, and perfecting themselves [24].
pace). Moreover, almost 60% of students believe that people's The concept of blended education facilitates such approaches
privacy is at risk due to social networks – a result that is and can trigger positive changes, satisfying for students, who
questionable, because not the social networks pose a danger, will benefit from flexibility and comfort, and, consequently,
but the people using them inappropriately – an aspect that also for teachers, who will have the satisfaction that their work
seems to have been omitted by students. Literature data also achieves its purpose and that the information they transmit is
confirms that the students, particularly the medical students, properly heard and acquired.
are not very well informed about the ethical issues regarding
the use of social media resources [21]. Conflicts of interest and sources of funding
The authors declare no conflict of interest. No financial support was received
There is an obvious and positive association between the
from any governmental institution, economic or non-governmental organization.
degree of agreement expressed by students towards the use
of multimedia resources during the learning process and their Authors’ contribution
favorable opinions towards the use of Internet services. This Conceptualization, C.G.D. and V.L.P.; methodology, C.G.D.; software, C.G.D. and
R.S.C.; validation, R.S.C.; formal analysis, C.G.D.; investigation, M.E.A. and R.S.C.;
means that the general openness to modern technologies is
resources, V.L.P.; data curation, C.G.D.; writing—original draft preparation,
reflected by integrating them into personal life, but also C.G.D. and M.E.A.; writing—review and editing, C.G.D. and V.L.P.; supervision,
professionally. On the other hand, unfavorable opinions V.L.P.; project administration, C.G.D. and M.E.A. All authors have read and
towards the use of Internet services are associated sometimes agreed to the published version of the manuscript.

with the general avoidance of modern technologies. We also

Patient consent for publication
identified a separate category of students who, although they Informed consent was obtained from all subjects involved in the study.
do not like to use multimedia resources in the learning
process, are instead very active on the Internet; they are Ethics approval and consent to participate
The study was conducted in accordance with the Declaration of Helsinki, and
especially interested in activities on social networks, without approved by the Ethical Committee of “Grigore T. Popa” University of Medicine
being very concerned about the other advantages provided by and Pharmacy from Iasi, Romania (decision no. 21/16.11.2020).
digital technologies. Anyway, the students who enjoy using

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 https://doi.org/10.55453/rjmm.2024.127.1.10
The article was received on May 14, 2023, and accepted for publishing on July 5, 2023.
ORIGINAL ARTICLE

The Impact of Physical Therapy on Psychomotor Functions in a Patient with Systemic Lupus
Erythematosus and Diabetes Mellitus – Case Illustrated Literature Review

Adina Geambaşu1, Remus R. Glogojeanu1, Lucian G. Eftimie1,2

1 National University of Physical Education and Sports, Bucharest, Romania
2 Carol Davila Central Emergency Military University Hospital, Bucharest, Romania

Correspondence: Remus Relu Glogojeanu, [email protected]

Abstract: The scientific and medical world is making permanent efforts to study, understand, and cure the complicated pathology
of Systemic Lupus Erythematosus (SLE) – the disease with 100 faces, due to the diversity and complexity of the symptoms. SLE
has a devastating impact on the patient’s life, causing multiple metabolic imbalances produced by both the disease itself and the
necessary medication. This case report addresses the therapeutic aspects of SLE and diabetes mellitus, on a 47-year-old male
with a sensitive multi-pathology and aggressive evolution, medication, and approaching psychomotor rehabilitation therapy, up
to now, when SLE treatment has ended. Also, this case study report highlights the importance of flexibility in the psychomotor
rehabilitation strategy, in the context of a large range of factors that influence its definition.

Keywords: SLE - systemic lupus erythematosus, diabetes mellitus, medication, recovery therapy, psychomotor

INTRODUCTION and/or gliclazide must be dosed by the treating physician

according to the particularities of the case [9,10]. It is well
The scientific and medical staff are making permanent efforts
known that diabetes can be controlled with careful diet and
to study, understand, and cure the complicated pathology of
weight monitoring, and physical exercise as a supplement to
Systemic Lupus erythematosus (SLE) [1-3]. SLE, an
medical treatment. That is why we consider the good
inflammatory autoimmune disease, also named the disease
collaboration between family, patient, doctor, and physical
with 100 faces due to the diversity and complexity of the
therapist, alongside the regular medical checkouts for blood
symptoms, has a devastating impact on the patient’s life due
variables of vital importance. The medical approach therapy is
to the multiple metabolic imbalances produced by the disease
individualized and customized to fit each patient's need
itself and the necessary medication [4].
depending on the type of disease and each symptom.
The etiology of SLE is unknown, as are the possible disorders
Reflection of the theme in specialized literature and
(but not necessarily) – hematological, nephrological,
conceptual boundaries
neurological, skin, and ocular, because of cellular and tissue
damage [5-7]. There is no chronological sequence of SLE Systemic lupus erythematosus (SLE) is a chronic autoimmune
manifestations, even in the same patient. It is problematic to disease with multisystem involvement. It is triggered by
diagnose, hard to treat (due to the various symptomatology deregulation of the immune system which, due to the
from minimum to severe), and difficult to continuously adapt autoantibodies produced, attacks the body's healthy cells and
the strategy of preserving psychomotor capacity, sometimes tissues. The clinical picture is very rich, it can affect several
necessary to change in an abrupt way. organs, it has an undulating evolution with periods of
exacerbation and remission, and the forms of presentation are
Diabetes Mellitus in the case of SLE is a particular situation
from clinical manifestations without life risk (affects the skin,
with the need for continuous monitoring because it can be
and joints) to potentially severe forms (affects the patient at
influenced by this long-term disease and its complex
neurological, renal, cardiovascular level).
medication treatment [8,9]. Administration of insulin units

74
There are 4 types of lupus: swollen, or red, the damage is usually symmetrical. Unlike
rheumatoid arthritis, lupus arthritis rarely causes severe joint
• Systemic lupus erythematous – is the most common form of
deformities and is not erosive.
lupus. The manifestation of the disease differs depending on
the affected structures. Hematological impairment

• Cutaneous lupus – manifests itself in the skin. Anemia, thrombocytopenia, leukopenia with neutropenia or
lymphopenia may occur within the disease or secondary to
• Lupus induced by drugs – iatrogenic lupus occurs as a
pharmacological treatment.
reaction to the administration of certain drugs.
Cardiovascular damage
• Neonatal lupus – is a particular form of the condition and
occurs due to the transplacental transmission of anti-Ro Pericarditis, myocarditis, and endocarditis can occur in this
antibodies from mother to fetus during pregnancy and can disease.
have skin, cardiac (the most serious being atrioventricular
Lupus endocarditis, called Libman-Sacks endocarditis, has no
block), hematological, and neurological manifestations.
infectious cause. Atherosclerosis occurs more frequently and
Symptoms can range from mild to very severe, and although develops more rapidly than in the general population.
they can be chronic, they usually come and go, with the
Lupus patients can also associate antiphospholipid syndrome
disease having an undulating course.
(SAFL), in which antiphospholipid antibodies are present (anti-
The most common complaints are fatigue, altered general beta 2 glycoprotein 1 antibodies, anti-cardiolipin antibodies,
condition, fever, lymphadenopathy (inflammation of the lupus anticoagulant).
lymph nodes), and joint and muscle pain. Almost any organ can
The presence of SAFL causes thrombosis), and spontaneous
be affected.
abortions.
Skin-mucosal damage
Lung damage
It is present in approximately 70% of patients. The classic
It can take the following forms: pleurisy, inflammation of the
manifestation of acute lesions is the heliotrope rash, erythema
pleura, pleurisy, pneumonitis, interstitial lung disease,
in "butterfly wings" present at the level of the nasal pyramid
pulmonary hypertension, and pulmonary thromboembolism.
and the cheeks (redness that extends from the nose to the
These can cause coughing, dyspnea (choking hazard), chest
cheeks, below the eye area), without affecting the nasolabial
pain, and hemoptysis.
folds. Erythema can also spread to other areas exposed to UV
radiation – forehead, chin, décolleté. Photosensitivity is Kidney damage (lupus nephritis)
another characteristic of lupus patients. Subacute lupus may
Renal damage determines the severity of the evolution of
initially present with erythematous lesions that, over time,
lupus patients. One-third of patients have kidney damage,
become papulosquamous, mimicking psoriasis or lichen
suggested by proteinuria or hematuria, serum creatinine is
planus. Discoid lupus erythematosus can appear on the face,
above the upper limit of the laboratory, and creatinine
scalp, ears, arms, hands, and back, the erythema being
clearance is low.
followed by hyperkeratosis or atrophy. Discoid lupus can be a
strictly dermatological lesion, without being accompanied by Neuropsychological impairment
systemic manifestations [29].
It is the least understood manifestation of systemic lupus
There may also be alopecia, skin purpura, erythema, small red erythematosus and one of the most severe. Among the
dots, urticarial eruptions, livedo reticularis, Raynaud's neurological manifestations, we mention convulsions, severe
syndrome, and ulcerations of the fingers pulp. Mucous headaches, peripheral neuropathies, cranial nerve damage,
membrane lesions consist of frequently painless petechial and cerebral vascular accidents, acute meningitis, and chorea.
ulceration of the nasal, oral, and, less commonly, genital Psychiatric manifestations include psychoses, cognitive
mucosa. dysfunction, anxiety syndrome, and mood disorders.

Musculoskeletal damage Gastrointestinal symptoms

About 90% of patients diagnosed with lupus will have joint The most common gastrointestinal symptoms are anorexia,
pain, arthritis, or muscle pain at some point. The joints of the nausea, vomiting, and abdominal pain, and may be
hands, fists, and then the large joints (knees, ankles, shoulders, manifestations of mesenteric vasculitis, peritonitis,
elbows) are most frequently affected. They can be painful, pancreatitis, or secondary to the administered medication.

75
Liver damage is found in up to 60% of patients – The cardiovascular and pulmonary systems can also be
hepatomegaly, increased liver enzymes, and hepatic steatosis. affected by lupus. We try to improve aerobic capacity through
Up to 8% of patients develop retinal artery inflammation with physical exercises and specific breathing exercises [31]. These
thrombosis at this level. The conjunctiva and cornea can be exercises will also contribute to maintaining a strong bone
affected by secondary Sjogren's syndrome [30]. system, as well as strengthening ligaments and joints. Regular
practice of sports activities is particularly recommended for
Specific immunological abnormalities
patients with lupus.
The presence of autoantibodies that target their own
Occupational therapy has the role of helping the patient regain
structures. Antinuclear antibodies (ANA) occur in
as much of his functional independence as possible, despite
approximately 95% of patients but have low specificity and
the problems caused by the disease. Activities of daily living
may be associated with other conditions (rheumatoid
are encouraged and may require training with special
polyarthritis, autoimmune thyroiditis, autoimmune liver
equipment, techniques, and procedures. These activities
diseases, infections, neoplasms, or in healthy individuals). The
include feeding, dressing, bathing, grooming, grooming, and
most frequent antibodies encountered in SLE are the
cooking in the home.
antibodies: anti-double-chain DNA (SLE specific, associated
with disease activity), anti-Sm (SLE specific), anti-U1 RNP, anti- A safety assessment at the patient's home may be indicated.
Ro, anti-La, anti-ribosomal protein P (SLE specific, appear in Occupational therapy can provide recommendations for
neurological, hepatic damage), anti-histones (occur in classical equipment (for example bathtub bench, elevated toilet seat,
and drug-induced lupus), anti-phospholipids (characteristics of grab bar) to increase the patient's independence and safety at
SAFL), rheumatoid factor (non-specific, occurs in many other home.
autoimmune conditions, infections). Decreased serum
Patients who have neuropsychiatric complications due to
complement fractions (C3, C4, CH50) are associated with
lupus may have cognitive dysfunctions, with deficits in
disease activity.
attention, language, and memory. The speech therapist can be
As is the case with many chronic conditions, systemic lupus helpful when a patient with systemic lupus erythematous has
erythematosus (SLE) negatively affects the quality of life, due slurred speech, difficulty understanding speech, or difficulty
to factors such as depression, pain, cognitive dysfunction, and speaking properly.
sleep disorders.
Because systemic lupus erythematosus is a condition that
Despite a little-understood etiology, fatigue is associated with manifests itself episodically, through bouts of activity
SLE in approximately 80% of cases, which leads to a decrease alternating with episodes of remission, it is important that the
in the level of physical activity necessary to carry out usual patient does nothing without consulting the rheumatologist
daily activities and thus dramatically decreases the quality of who deals with his disease – thus, it will reduce the risk of
life. triggering a set of activities.

Physical medicine and recovery in Systemic Lupus Unfortunately, there is still no treatment that can cure lupus,
Erythematous may involve physical therapy, occupational but there are treatments that can improve the symptoms
therapy, speech therapy, recreational therapy, or while prolonging the episodes of remission of the disease.
combinations thereof. The specialist doctor should coordinate Adopting a healthy lifestyle also contributes to increasing the
the patient's care and be attentive to subtle changes in quality of life of the lupus patient.
symptoms that may indicate periods of disease activity [32].
Other things that the lupus patient can do to improve their
Ultrasound is a frequently used procedure to provide heat in condition:
the depth of the affected joint, but it should not be used in the
• To give up smoking, but also the consumption of caffeine or
presence of inflammation; locally applied ice is the preferred
alcohol.
method for inflamed joints. When ultrasound is used to
improve joint mobility, the application of ultrasound and joint • To adopt a healthy, balanced diet, based on as many natural
movement should be simultaneous. foods as possible.

Hydrokinetic therapy is recommended for the mobilization of • To rest enough.

inflamed joints, due to the buoyancy that ensures the
• Follow exactly the treatment recommended by the doctor,
unloading of the joint and the soothing action of the warm
even during periods of remission of the disease.
water.
• To avoid exposure to the sun because ultraviolet radiation

76
increases the risk of triggering a flare-up of systemic lupus unbalanced alimentation (almost exclusively processed meat
erythematous. products/minced meats and semi-prepared products, and
carbonated beverages), smoking, stress, lack of sleep,
It is recommended to reduce exposure to UV rays (using
improper self-medication for diabetes mellitus, sustained
creams with a minimum sun protection factor of 50, avoiding
effort.
exposure to the sun), a diet adapted to the patient undergoing
corticosteroid therapy (to prevent its adverse effects – - The SLE treatment itself begins in February 2018, the
diabetes, hypertension, dyslipidemia), quitting smoking. patient’s previous treatment included only medication for his
symptoms - edema, hypertension, cytopenia, etc.
To prescribe a drug treatment, it is essential to identify the
type of organ damage and its severity. - In his delicate condition, with the complex ongoing
treatment, the patient beneficiated from the support of his
Non-life-threatening damage (skin-mucous, musculoskeletal,
family, nutritionist, priest, and doctors which improved his
serositis) is indicated for the administration of non-steroidal
mental state of being.
anti-inflammatory drugs, low-dose systemic cortico-therapy,
and synthetic antimalarials. - The period 2018-2019 was an equilibrated one when the
patient was under observation, good nutritional plan, and 3
Potentially vital damage (cardio-pulmonary, hepatic, renal,
weekly sessions of physical therapy.
hematological, central nervous system) requires cortico-
therapy in moderate or high doses, associated depending on - In February 2022 the patient gets infected with SARS-CoV-2
the affected organ, with immunosuppressants, anticoagulants, Covid 19 Omicron Type which lead to a 10 days hospitalization
anticonvulsants, or even biological therapy. in the nephrology unit medical care.

Systemic lupus erythematosus is a chronic condition with - The clinical picture of the subject presented above starts from
multisystem involvement that presents severe evolutionary the aggressive debut in the autumn of 2017 until 2021. We
potential. Currently, thanks to advances in the knowledge of mention that multi-pathology and all associated diagnoses are
mechanisms, diagnosis, and treatment, the 10-year survival not included in this presentation.
rate of lupus patients is almost 90% [30].
We also mention that during this period of multiple
hospitalizations, there were diagnosed multiple associated
MATERIALS AND METHODS
pathology such as Diabetes mellitus type 2 with established
This review started with a case study and addresses the Diabetic Nephropathy, Hypertensive Nephropathy with Renal
therapeutic aspects of SLE and Diabetes Mellitus of a 47-year- Impairment, Hyperuricemia without signs of Inflammatory
old male with a delicate multi-pathology and aggressive Arthritis or Tophaceous Disease, Vulgar Ichthyosis, Glomerular
evolution, caused by both the diagnostic and the difficult disorders in systemic connective tissue disorders, other water
approach of the psychomotor rehabilitation therapy when SLE and electrolyte disturbances not elsewhere classified, Anemia
treatment has ended. In this case study report, we approach in other chronic diseases classified elsewhere, Non-
the importance of the management of the disease combining inflammatory Pericardial infusion, Medication-induced
not only the multiple therapeutic actions but also the proper Specific Polyneuropathies, Secondary hypertension of other
medication and nutrition and the psychomotor rehabilitation kidney disorders, Ascites, Hypo-osmolality and hyponatremia,
[11]. The study includes stages of life-threatening biological Chronic nephritis syndrome, etc.
depreciation, and treatment, until the present when the
Also, here are some additional landmarks: the dietary regimen
therapy is positively affecting the patient's quality of life.
consisted of predominant vegetarian and hypoglycemic food,
We present the short version of the patient's clinical history: water management with 500 ml more than the urinary
removal, medical plant tea indication, measurement of food in
- At 27 years old, he underwent surgery for Non-Hodgkin's
carbs no more than 150 per day (50/50/50 for each meal)
Lymphoma, associated with polychemotherapy and
associated with the prescribed medication; glycemic test each
radiotherapy, with good response, in remission and without
day before meals with calculated insulin administration (rapid
any specific medication from 2003.
and long-acting insulin) and/or gliclazide.
- No forms of SLE manifestation until 2017.
The multidisciplinary team of doctors (diabetologists,
- The aggressive form of SLE debuted in September 2017, nephrologists, cardiologists, and Physiotherapists) [12-17]
caused by an unstable lifestyle associated with many followed the patient during all the periods.
detrimental factors accumulated in the last 15 years:

77
Treatment of SLE with the administration of combined diuretic evaluated in how many meters the patient succeed to go on,
treatment: high-ceiling diuretics (furosemide), Vasopressin at the end of the session.
antagonists (tolvaptan), Diuretic thiazide and potassium-
5. The patient on the ergometric bicycle without lumbar
sparing (amiloride hydrochloride and hydrochlorothiazide),
support, with a distance between the hip and the pedals so
thiazide diuretics (hydrochlorothiazide) and immune-
that the knee is slightly flexed, without load, he pedals freely
suppressive combination (cyclophosphamide, mycophenolate
at a slow pace, following the heart rate so that it does not
mofetil), cyclosporine and corticosteroids (prednisolone).
exceed 120 beats/min, it is marked how many minutes he can
Evaluation methods pedal up to the indicated maximum cardiac effort, or any other
sign of imbalance, dizziness, numbness or pain. The test was
To carry out this research from the Physiotherapists point of
held at the end of the physical therapy session.
view, we chose the following measurements and evaluation
tests: Evaluation Instruments

1. to assess the level of the peripheral inflammatory stage at The used instruments were a tape measure, goniometer,
the level of the lower limbs as well as that of the muscle mass stopwatch, liner, ergometric bicycle, and pulse tester.
of the subject, we performed the anthropometric-perimetry
Research methods used
method for the ankle and calf.
The research methods used in the paper were:
2. to evaluate the degree of mobility of the lower limb
necessary for functionality, we used the goniometric method - the theoretical documentation method.
for the ankle and hip joints.
- pedagogical observation.
3. to assess static balance, we used the simple bipedal balance
- the experimental method.
test with eyes open with several penalties for imbalance for 5
minutes. - the method of tests and evaluation samples.

4. to assess dynamic balance we asked the patient to walk on - the investigation method.
a drawled line of 5 meters distance, eyes open, without
- the method of recording and statistical-mathematical data
imbalance, dizziness, or lateral support.
processing.
5. to evaluate the subject's effort capacity, we used the
- the graphic method.
ergometric bike without resistance with heart rate
measurement. Applied intervention

Description of the used methods To streamline and synthesize the process of describing
exercises applied, they are presented below (Tables 1 and 2).
1. The patient is in the supine position, and the measuring tape
is applied at the level of the ankle joint including the most The tables show the means we worked with, the exercise
inflamed area, measuring an average of the right/left ankles program proposed for every period, and their dosage.
before the physical therapy program. Teaching materials used to fulfill the improvement program of
2. The patient lying on his back, and the goniometer is applied motor functional skills and of balance and effort capacity were
according to the goniometric measurement and evaluation the stick, a small hand weight 1 kg, a terra band, the balance
standards of the ankle and hip joint for the flexion movement, board, the inflatable balance disc, the gym ball, the small
before the physical therapy program. spikes ball for prehension, the bicycle, marker.

3. The patient in the standing position with bare feet on the The physical therapy program no. 1 consisted of this period in:
floor for better plantar kinesthesia, eyes open, is timed for specific exercises that do not involve risks factors for strokes,
how many minutes/seconds he can stand without imbalances, bruises, or bleeding; exercises that do not present risk factors
dizziness, or lateral support. The evaluation was carried out at for a patient with high blood pressure; exercises and
the beginning of the meeting for static balance. techniques for lymphatic drainage; specific techniques for
tone muscle and equilibrium; specifically adapted methods for
4. For dynamic balance, a 5m line was marked on the floor, and
connective flexibility and joints mobility; programs for
the patient was asked to follow the line walking, eyes open,
developing effort capacity; outdoor adapted program;
marking any sign of imbalance, dizziness, or lateral support,
exercises that consider the electrolyte imbalance (already
existing due to the disease); breathing exercises.

78
 Table 1: The process of describing initial exercises applied – the first program
Reps or Pause
Type of method Exercise Series
seconds/minutes (sec)
Mobilization From the lying position - slow passive mobilization of the ankle in all
3 30 reps 30 sec
directions
From the lying position - slow passive mobilization of the knee for flexion
3 15 reps 30 sec
and extension
From lying position - Slow passive mobilization of the hip in all ranges of
3 15 reps 60 sec
motions from simple to complex
From lying position and sitting - Active mobilization of the upper limbs
3 15 reps 60 sec
with a stick in all ranges of motions
From lying position - Free active mobilization of the upper limb in all
3 15 reps 30 sec
ranges of motions
From lying position - Free active mobilization of lower limbs in all ranges
3 15 reps 60 sec
of motion (bicycle, shears, bypasses)
Quadrupedal position, cat forward and backward 3 10 120 sec
Tone muscle Lying position - all range motion mobility with 1-kg hand weights 3 15 60 sec
Sitting position - all range motion mobility with 1-kg hand weights 3 15 60 sec
Sitting position - terra band extension between arms in abduction and
3 10 120 sec
extension
Sitting position - leg extension with a terra band resistance 3 10 120 sec
Lying position - knee flexion and extension with terra band resistance 3 10 reps 120 sec
Static balance Sitting position - imbalance from the shoulders in all directions with the
requirement to maintain the posture from the abdomen without the 3 10 reps 60 sec
help of the hands
Standing position - Keep abduction of the hands 3 10-60 seconds 120 sec
Standing position - maintain the balance without lateral support or
3 10-60 seconds 120 sec
movements
Dynamic Standing position - Raise 1 leg on a support ball 3 10-60 seconds 60 sec
balance
Standing position - walking with a plastic cup with water in the hand 3 10 m 60 sec
Standing position - walking on a drawled line on the floor without lateral
3 10 m 120 sec
support or lateral deviations
Standing position - with lateral or face hand support - on a balance
3 10 reps 120 sec
platform or ball - back straight, crunches
Standing position - lateral support - kick a ball 3 10 reps 60 sec
Effort capacity Bicycle ride - level 0 1 5 min -
Bicycle ride - level 0 1 15 min -
Claiming stairs from 1 to 3 floors 1 15-30 min 5 min
Outdoor Walking outdoors on a parc with support (frame, cane or crutch, or
1 15-30 min -
training human lateral support)
Breathing Lying position - costal and abdominal breathing techniques, slowly and
1 5- 10 min -
techniques following the dizziness or pain
Sitting position - gently inhale with the extension of the trunk and arms,
and exhale slowly and long with the return and withdrawal of the navel 1 5-10 min -
towards the spine.
Manual Manual lymphatic drainage and pump exercises 1 15 – 30 min -
techniques
Manual therapy for connective tissues 1 15-30 min -

All exercises and techniques were adapted to the daily a frequency of 3 sessions per week (Monday, Wednesday,
dynamic state of functionality of the patient from very simple Friday), the duration of the session being between 30 and 120
basic to the maximum possible in his case. The programs were minutes depending on the daily state of the patient and the
carried out on an outpatient basis at the patient's home, with applied methods.

79
 Table 2: The process of describing initial exercises applied – the second program
Reps or Pause
Type of method Exercise Series
seconds/minutes (sec)
Mobilization From the lying position - slow active mobilization of the ankle in all
3 30 reps 30 sec
directions
From the lying position - slow active mobilization of the knee for flexion
3 15 reps 30 sec
and extension
From lying position - Slow active mobilization of the hip in all ranges of
3 15 reps 60 sec
motions from simple to complex
From lying position and sitting - Active mobilization of the upper limbs
3 15 reps 60 sec
with a stick in all ranges of motions
From lying position - Free active mobilization of the upper limb in all
3 15 reps 30 sec
range of motions with 1 kg hand weights
From lying position - Free active mobilization of lower limbs in all ranges
3 15 reps 60 sec
of motion with 1 kg leg weights (bicycle, shears, bypasses)

Quadrupedal position, cat forward and backward 3 10 120 sec

Tone muscle Face lying position - all range motion mobility with terra band 3 15 60 sec
Sitting position - all range motion mobility with 1 kg hand weights 3 15 60 sec
Sitting position - terra band extension between arms in abduction and
3 10 120 sec
extension
Sitting position - leg extension with a terra band resistance or 1 kg leg
3 10 120 sec
weights
Lying position - knee flexion and extension with terra band resistance or
3 10 reps 120 sec
1 kg leg weights
Static balance Sitting position - imbalance from the shoulders in all directions with the
requirement to maintain the posture from the abdomen without the 3 10 reps 60 sec
help of the hands or with a ball or a weight of 1 kg in the hands
Standing position - Keep abduction from 90O - 180O of the hands 3 10-60 seconds 120 sec
Standing position - maintain the balance without lateral support or
3 10-60 seconds 120 sec
movements and keep a 1 kg weight on the hands
Dynamic Standing position - Raise 1 leg on a support ball with 1 kg leg weight 3 10-60 seconds 60 sec
balance Standing position - walking with a 1 kg weight on the hand 3 10 m 60 sec
Standing position - walking on a drawled line on the floor without lateral
support or lateral deviations with a cup of plastic water in the hand or on 3 10 m 120 sec
the head
Standing position - with lateral or face hand support- on a balance
3 10 reps 120 sec
platform or ball - back straight, squats or lunges
Standing position - lateral support - kick a ball or roll a 1 kg leg weight 3 10 reps 60 sec
Effort capacity Bicycle ride - level 1 1 5 min -
Bicycle ride - level 1 1 15 min -
Claiming stairs from 1 to 6 floors 1 15-30 min 5 min
Outdoor Walking outdoors on a parc with or without support (frame, cane or
1 15-30 min -
training crutch or human lateral support)
Breathing Standing position - costal and abdominal breathing techniques, slowly
1 5- 10 min -
techniques and following the dizziness or pain
Standing or quadrupedal position - gently inhale with the extension of
the trunk, leg, and arm, and exhale slowly and long with the return and 1 5-10 min -
withdrawal of the navel towards the spine
Manual Manual lymphatic drainage and pump exercises 1 15 – 30 min -
techniques Manual therapy for connective tissues 1 15-30 min -

The program contains breathing exercises from decubitus and limbs at the bedside level, lymphatic drainage, progressive
sitting, easy mobilization exercises for upper limbs with the passive mobilizations, progressive active spine mobilizations,
stick and weights no more than 1 kg, slow exercises for lower static and dynamic equilibrium methods, core and leg muscle

80
tone exercises, home bicycle program from 0 weight, outdoor for outdoor walking without the support and on uneven
walking sessions. Monday and Wednesday were addressed to terrain, effort capacity development on the bicycle with
the indoor program and Friday evening (due to the ocular and resistance, maneuverability, and coordination exercises.
skin problems in SLE) if the weather was proper and the state
The program contains breathing exercises from sitting and
of the patient was a good one, was addressed to the outdoor
standing positions, mobilization, and tonus exercises for upper
program.
limbs with the stick and 1 kg weight, exercises for lower limbs
Objectives at the bedside level and from standing position with terra
band, abdominal and diaphragmatic exercises, equilibrium
The 1 physical therapy program followed the objectives of
exercises with or without lateral support, progressive active
each period of the evolution of the patient’s state.
mobilizations, prehension exercises, lymphatic drainage, and
The initial objectives of the treatment were those of: manual therapy, bicycle training, outdoor walking sessions.
- preserving life
All exercises and techniques were adapted to the daily
- following developments in functionality and evasion of
dynamic state of functionality of the patient following the rule
complications.
of "primum non nocere" [26].
The main objectives were:
Objectives
- Improve the quality of life
- Decrease in inflammation and lymph retention The 2 physical therapy programs followed the objectives of
- Preserve and gain flexibility each period of the evolution of the patient’s state.
- Develop tone muscle
The initial objectives of the treatment were those of:
- Develop a functional effort capacity
- preserving the quality of life and existent functionality
- Obtain a good static and dynamic stability
- following developments in functionality and evasion of
- Maintain a good psychological state of mind and optimism
complications.
with the patient and family.
The main objectives were:
The functional state of the patient translates into functional
- Improve the quality of life
disability to service and personal care, unable to have an
- Preserve and gain flexibility and connective tissue elasticity
orthostatic position, seated posture, and displacement.
- Develop tone muscle and regain muscle mass
The physical therapy program no. 2 consisted of the same - Gain a functional effort capacity for outdoor functionality
exercises as in the first period but improved and adapted to - Obtain good static and dynamic stability together with
the new daily possibilities of the patient. Such as upper and coordination skills
lower limb mobilization in a full range motion and with - Maintain an optimistic continuous psychological state of
resistance, static and dynamic balance improved techniques mind and optimism with the patient and family.

Figure 1: Representative images of the foot edema and neuropathy skin lesions

81
The recovery protocol consisted of tracking the functionality between the initial, intermediate, and final evaluations of the
of each step according to the patient's evolution, following the dimensions by 6 centimeters for the ankle joint and by 8
food and drug indications and the degree of muscle and joint centimeters for the calf, relevant to a good drainage process
recovery, and also considering the equilibrium function that both through the function of the kidney and through the
has been greatly affected. lymphatic system, due to both effective medication and the
sustained kinetic program.
During these months of complex treatment, the patient had
positive or stagnant recovery moments, being affected by
atmospheric pressure temperature, and climate change.

The purpose was to perform standing posture and walking

with a moderate balance and state of equilibrium.

The functional state of the patient in March 2021 was that of

functional and personal care integrity, the ability to perform
standing posture, and walking with a moderate balance and
state of equilibrium (Figure 3).

The patient continued the prescribed programs on his own at

home during the pandemic period and the functional state of
the patient in June 2022 was that of functional and personal
care integrity, the ability to perform standing posture and
walking with a moderate balance, and a state of equilibrium.
(Figure 4).

RESULTS

The results concerning our patient were very promising (Table

3).
Figure 2: Representative images of the foot edema and neuropathy
The perimetric measurements showed a constant decrease skin lesions

Figure 3: Representative images of the foot from March 2021.

82
 Figure 4: Representative images of the foot from June 2022.

The goniometric measurements for ankle and hip flexion had degrees and the hip 55 degrees in a range of motion, which
values of increased joint mobility, thus the ankle gained 10 allowed the patient better mobility and dynamic functionality.

Table 3: Results of evaluation tests

Initial testing Intermediary Final testing
Measurements Observations
Feb 2017 testing Feb 2018 March 2019
Ankle perimeter 30 cm 27 cm 24 cm Decreased by 6 cm
Calf perimeter 45 cm 43 cm 37 cm Decreased by 8 cm
Ankle flexion mobility 5O 10O 15O Improved with 10O
Hip flexion mobility 35O 85O 90O Improved with 55O
Static stability 0 5 min 10 min Improved 10 min
Dynamic stability 0 10 meters 30 meters Improved 30 meters
Effort capacity 0 10 min 15 min Improved 15 min

The evaluation of static stability recorded beneficial increases

for the patient's life from the value of 0 minutes to 10 minutes
without imbalance. The dynamic stability tests increased from
0 meters to 30 meters of walking without imbalance and
support. Thus, the static stability gained 10 minutes without
imbalances, and the dynamic one from value 0 reached a
displacement of 30m without imbalances and support, which
allowed the patient to go outside the house.

Figure 6: Ankle and hip flexion mobility results

Figure 5: Ankle and calf perimeters measurements results

Figure 7: Static and dynamic stability evaluation results

83
The evaluation of the effort capacity from 0 initial value has the presence of the SLE patient in the community over long
reached 10 minutes without effort disorders so that later on periods of time, even more in the presence of other patients
the final evaluation on the best day of the patient will be 15 with transmissible diseases).
minutes without effort disorders. We mention that every day
• And additionally, where appropriate, to apply therapeutic
the patient's dynamics undergo changes from one hour to the
manual therapy and drainage sessions, as well as breathing
next and the time of day matters a lot.
techniques.

The recommended strategy for addressing the rehabilitation

of motor function in such a complex case requires monitoring
of at least these five levels of observation:

- Always be aware of the disease progression (even more in the

context of risk of relapse) and medication administration,
constantly consult physician recommendations, the results of
medical tests, imagistic investigations, and so on. In this case,
multiple impairments of the organ systems have led to chronic
or acute manifestations of imbalances in the body [21-25,33,
Figure 8: Effort capacity results. 34]. Permanently check the treatment schedule, especially in
the case of a long-term treatment plan disease with the
DISCUSSION
adjustment of the substances and doses used (side effects of
The recommended strategy for addressing such a complex SLE drugs can often have an impact on the patient's condition).
case, for recovery of motor function, requires monitoring of at
- Permanent assessment of the patient’s evolution, in points
least three lines of observation:
where difficulties were found posture, coordination, and
1 Always be aware of disease progression (more in the context motricity, cause many of the associated diseases, both in the
of risk of relapse of disease) and medication applied: kidneys and other organs, make it difficult to choose the
correct and balanced diet and medication.
• Consulting physician recommendations, the results of
medical tests, imaging investigations, etc. - An important path leading to complete rehabilitation in this
case, as in many others, was the combination of sustained
• Check the treatment schedule, especially in the case of a
social - psychological - spiritual support through faith and
disease involving a long-term treatment scheme with the
management with attention focused on the patient. The
adjustment of the substances and doses used (side effects of
psychological support received from the medical staff and
drugs can often have an impact on the patient's condition).
family, largely based on the patient’s trust in them, was even
2 Use in an efficient manner the pluses of a positive psychic more necessary as the treatment with corticosteroids can
state (a calm, orderly mind with clear targets) and cultivate the cause changes in behavior (periods of extreme energy and
will of the patient. activity, combined with periods of insomnia and irritability).
We identified at least three main engines of the patient’s
3 Permanent assessment of patient evolution, in points where
desire to recover – confidence in the attending physician and
difficulties were found: posture, coordination, and motricity.
successful completion of the treatment, the desire to return to
Following the lines of this strategy, the physical therapist will a normal life and sacred therapy.
be able:
The multi-pathology, as well as the delicate situation of the
• To work together with the patient, in a flexible system, the patient, have greatly raised the stakes of the entire medical
recovery exercises - maximum 10-30 minutes. staff in choosing the most suitable treatment management,
which is still in progress daily.
• To recommend to the patient a set of exercises to perform
at home (immunosuppressive regimens do not recommend

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(year); (vol): [issue].
subjects under the study should be omitted. Photographs need to be cropped
sufficiently to prevent human subjects from being recognized (or an eye bar Review Articles
should be used). RJMM welcomes reviews of important topics across the scientific basis of
Registration of Clinical Trials medicine and advances in clinical practice. Most published reviews are in
response to the editorial invitation, including thematically related “miniseries”
We strongly recommend, as a condition of consideration for publication,
of reviews. Authors considering submitting a review for RJMM are advised to
registration in a public trials registry. Trials register at or before the onset of
canvas their possible review with the Editor-in-Chief or a colleague editor; this

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avoids early rejection if the subject matter is not deemed a high priority for the Trade names
Journal at the time of submission. Reviews are suggested to limit to 3500–5000 Trade names should not be used. Drugs should be referred to by their generic
words, with an abstract of up to 200 words and up to 100 references and figures names, rather than brand names.
or tables.
Parts of the Manuscript
Meta-Analyses or Systematic Reviews
The manuscript should be submitted in separate files: the title page; the main
RJMM particularly welcomes the submission of Meta-Analyses and Systematic text file according to the word model.
Reviews, which underpin evidence-based medicine. Guidelines for the
Title page
preparation of Meta-Analysis and Systematic Reviews are similar to other
reviews, and articles are subject to the usual peer review process. Meta-Analyses The title page should contain (i) a short informative title that contains the major
and Systematic Reviews are suggested to limit to 3500–5000 words, with an keywords. The title should not contain abbreviations; (ii) the full names of the
abstract of up to 200 words and up to 100 references and figures or tables. authors (if possible, not more than 5 authors per title); (iii) the author’s
institutional affiliations at which the work was carried out; (iv) the full postal and
Original Articles (including clinical trials)
email address, plus telephone number, of the author to whom correspondence
RJMM welcomes original articles concerned with clinical practice and research about the manuscript should be sent; (v) disclosure statement; and (vi)
in the fields of medicine. Papers can cover the medical, surgical, radiological, acknowledgments. The present address of any author, if different from that
pathological, biochemical, physiological, ethical, and/or historical subject areas. where the work was carried out, should be supplied in a footnote.
Clinical trials are afforded expedited publication if deemed suitable. RJMM also
Disclosure statement
deals with the basic sciences and experimental work, particularly that with clear
relevance to disease mechanisms and new therapies. Original articles are The source of financial grants and other funding should be acknowledged,
suggested to limit to 3000 words, with an abstract of up to 200 words and up to including a frank declaration of the authors’ industrial links and affiliations. In
100 references and figures or tables. the case of clinical trials or an article describing the use of a commercial device,
therapeutic substance or food must state whether there are any potential
Education and Imaging
conflicts of interest for each of the authors: failure to make such a statement
The Editors welcome contributions to the Education and Imaging section. The may jeopardize the article being sent out for peer-review.
purpose is to present imaging for the evaluation of unusual features of common
Acknowledgments
conditions or diagnosis of unusual cases. Contributions will be reviewed by the
Executive Editors. The format of the Images pages involves two parts, each of The contribution of colleagues or institutions should also be acknowledged.
which will occupy up to one journal page. In part 1, a case will be described Thanks to anonymous reviewers are not allowed.
briefly, including a summary of the presentation, clinical features, and key Main text
laboratory results. One to two key images will then be presented. It is helpful to
As papers are double-blind peer-reviewed the main text file should not include
the reader if the author responds to questions that follow from the images of
any information that might identify the authors. The main text of the manuscript
the case, such as ‘What is your diagnosis? What are the features indicated on
should be presented according to the word model. Figures and supporting
the CT scan? What is the differential diagnosis?’ Part 2 will briefly describe the
information should be submitted as separate files. Footnotes to the text are not
imaging features, particularly those that lead to a diagnosis or are critical for
allowed and any such material should be incorporated into the text as
management. Differential diagnosis should be mentioned. It will be useful to
parenthetical matter.
include either further images or pathological details that validate the imaging
diagnosis. Occasionally, the presentation of analogous cases or related images Abstract and keywords
from a similar case might be appropriate. Original articles must have a structured abstract that states in 200 words or less
Please include between one and three references to definitive studies and the purpose, basic procedures, main findings, and principal conclusions of the
appropriate reviews of the subject. The format of the Images page involves a study. If appropriate, divide the abstract with the headings: Background and
brief background and description of the disorder of interest together with two Aim, Methods, Results, and Conclusions. The abstracts of reviews need not be
figures of high quality. Colored photographs are encouraged. The submission structured. The abstract should not contain abbreviations or references. Three
may take the form of a case report or may illustrate particular features from to ten keywords should be supplied below the abstract and should be taken from
more than one patient. those recommended by the US National Library of Medicine’s Medical Subject
Headings (MeSH) browser – http://www.nlm.nih.gov/mesh/meshhhome.html.
MANUSCRIPT PREPARATION
Text
Style
Authors should use the word form in editing the submitted material.
Manuscripts should follow the style of the Vancouver agreement detailed in the
References
International Committee of Medical Journal Editors’ revised ‘Uniform
Requirements for Manuscripts Submitted to Biomedical Journals: Writing and The Vancouver system of referencing should be used. In the text, references
Editing for Biomedical Publication, as presented at http://www.ICMJE.org/. should be cited using Arabic numerals in square parentheses in the order in
which they appear. If cited only in tables or figure legends, number them
Spelling
according to the first identification of the table or figure in the text. In the
The journal uses US spelling and authors should, therefore, follow the latest reference list, the references should be numbered and listed in order of
edition of the Merriam-Webster’s Collegiate Dictionary. appearance in the text. Cite the names of all authors when there are six or fewer;
Units when seven or more list the first three followed by et al. Names of journals
should be abbreviated in the style used in MEDLINE. Reference to unpublished
All measurements must be given in SI units as outlined in the latest edition of
data and personal communications should appear in the text only.
Units, Symbols and Abbreviations: A Guide for Biological and Medical Editors and
Authors (Royal Society of Medicine Press, London). Use Index Medicus as the style guide for references and other journal
abbreviations.
Abbreviations
Tables
Abbreviations should be used sparingly and only where they ease the reader’s
task by reducing the repetition of long technical terms. Initially use the word in Tables should be self-contained and complement, but not duplicate, the
full, followed by the abbreviation in parentheses. Thereafter use the information contained in the text. Number tables consecutively in the text in
abbreviation. Arabic numerals. Type tables on a separate page with the legend above. Legends
should be concise but comprehensive – the table and legend must be

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understandable without reference to the text. Column headings should be brief, must comply with acceptable international standards (such as the Declaration of
with units of measurement in parentheses; all abbreviations must be defined in Helsinki) and this must be stated.
footnotes. Footnote symbols: †, ‡, •, ‣ should be used (in that order) and *, **, – For research involving pharmacological agents, devices, or medical technology,
*** should be reserved for P-values. Statistical measures such as SD or SEM a clear Conflict of Interest statement about any funding from or pecuniary
should be identified in the headings. interests in companies that could be perceived as a potential conflict of interest
Figure legends in the outcome of the research.
Type figure legends on a separate page. Legends should be concise but – For clinical trials, these have been registered in a publically accessible database
comprehensive – the figure and its legend must be understandable without (see more under ‘ETHICAL CONSIDERATIONS (Further Information)’ later in these
reference to the text. Include definitions of any symbols used and define/explain guidelines).
all abbreviations and units of measurement Indicate the stains used in If the above items are not included in the cover letter, manuscripts cannot be
histopathology. Identify statistical measures of variation, such as standard sent for review. Please also note that the cover letter does not require a detailed
deviation and standard error of the mean. or lengthy description of the content or structure of the manuscript itself.
Figures Two Word files need to be included upon submission: A title page file and the
All illustrations (line drawings and photographs) are classified as figures. Figures main text file that includes all parts of the text in the sequence indicated in the
should be numbered using Arabic numerals, and cited in consecutive order in section ‘Parts of the manuscript’, including tables and figure legends but
the text. Each figure should be supplied as a separate file, with the figure number excluding figures which should be supplied separately.
incorporated in the file name. The main text file should be prepared using the word model that is to be found
Preparation of Electronic Figures for Publication: on the web page (http://revistamedicinamilitara.ro/wpcontent/uploads/
Although low-quality images are adequate for review purposes, publication 2022/07/Macheta-articole.docx).
requires high-quality images to prevent the final product from being blurred or Each figure should be supplied as a separate file, with the figure number
fuzzy. incorporated in the file name. For submission, high-resolution figures (at least
300 d.p.i.) saved as .eps, .jpg or .tif files are required.
SUBMISSION REQUIREMENTS
Manuscripts should be submitted online at [email protected]. A cover letter PUBLICATION PROCESS AFTER ACCEPTANCE
containing an authorship statement should be included. The cover letter should Accepted Articles
include a statement covering each of the following areas: Accepted Articles are published online after final acceptance, and appear in PDF
– Confirmation that all authors have contributed to and agreed on the content format only.
of the manuscript, and the respective roles of each author. It is not accepted the Proofs
idea of equal contribution.
Once the paper has been typeset, the corresponding author will receive an e-
– Confirmation that the manuscript has not been published previously, in any mail alert containing the proof of acceptance. It is therefore essential that a
language, in whole or in part, and is not currently under consideration working e-mail address is provided for the corresponding author.
elsewhere.
COPYRIGHT, LICENSING, AND ONLINE OPEN
– A statement outlining how ethical clearance has been obtained for the
research, particularly concerning studies involving human subjects, and animal Details are on the Copyright Agreement Form that must be completed and
experimentation. The institutional ethics committees approving this research signed when the Article is submitted.

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 New Series, Vol. CXXVII, No 1/2024, January
ISSN-L 1222-5126; eISSN 2501-2312; pISSN 1222-5126